Kun, L, Baretich, MF."Biocomputing The Electrical Engineering Handbook Ed. Richard C. Dorf Boca raton crc Press llc. 2000
Kun, L., Baretich, M.F. “Biocomputing” The Electrical Engineering Handbook Ed. Richard C. Dorf Boca Raton: CRC Press LLC, 2000
117 Biocomputing 117.1 Clinical Information Systems Luis Ki and the Cis Integration.Smart/Optical Cards Matthew e. Baretich 117.2 Hospital Information Systems niversity of Colorado The Clinical Environment Healthcare Codes and Standards 117.1 Clinical Information Systems Luis Kun The main objective of this section is to provide the reader with a summary of areas that relate to clinical information systems. Since this field is so wide, the following topics will be covered mainly because of their importance within the field of medical informatics and the impact that these areas will have in healthcare delivery in the near future. At the end of this section there is a list of definitions that should help the reader not used to related acronyms and a list of suggested bibliographic references which should allow those interested to further increase their knowledge Computer-Based Record Besides improvements in patient care, enhancing the productivity of physicians, nurses, and all healthcare related personnel is very high on the agenda of all hospitals Hospitals, clinics, HMOs, doctors offices, emer- gency care centers, group practices, laboratories, radiology clinics, and nursing homes among others have a need to share patients' records. Aside from the direction that all of these medical-related centers will have with a required connection to the insurance companies/agencies to speed up payments and their accuracy, the growing need is to have the ability to transfer patients'medical files electronically anywhere in the world. As medical centers become more competitive, they will become worldwide centers of excellence for their given cialties. In turn then, their services will be marketed to the entire world population, becoming true global resources The trend of converting hospitals into"paperless hospitals"is becoming one of the most important topics of the 1990s. In 1970, chartered by the National Academy of Sciences, the Institute of Medicine working under the Policy Matters for Public Health has actively pursued the creation of a computer-based record( CBr). In July of 1991 a book was published by the Institute of Medicine in regards to the CBr. The requirements to ompile an all-digital medical record(ADMR)will require ways to combine data, graphics, voice, signals, and images, both clinical and document. The architecture that will accommodate all these forms of information for capturing, storing, communicating, and displaying is extremely complex. Some of the technologies involved include optical fibers, LANS, compact/optical disks, bedside terminals, medical image display stations, image diagnostic workstations, and picture archival and communications systems to name a few The High Performance Computing and Communications Initiative(HPCCI)was signed into law in Decem- ber of 1991. Although most of the emphasis for this initiative was from a research and academic sense, some c 2000 by CRC Press LLC
© 2000 by CRC Press LLC 117 Biocomputing 117.1 Clinical Information Systems Computer-Based Record • Clinical Information Standards • Bedside Terminals/Point-of-Care Systems • Imaging and the CIS • Systems Integration • Smart/Optical Cards 117.2 Hospital Information Systems The Clinical Environment • Healthcare Codes and Standards 117.1 Clinical Information Systems Luis Kun The main objective of this section is to provide the reader with a summary of areas that relate to clinical information systems. Since this field is so wide, the following topics will be covered mainly because of their importance within the field of medical informatics and the impact that these areas will have in healthcare delivery in the near future. At the end of this section there is a list of definitions that should help the reader not used to related acronyms and a list of suggested bibliographic references which should allow those interested to further increase their knowledge. Computer-Based Record Besides improvements in patient care, enhancing the productivity of physicians, nurses, and all healthcarerelated personnel is very high on the agenda of all hospitals. Hospitals, clinics, HMOs, doctors’ offices, emergency care centers, group practices, laboratories, radiology clinics, and nursing homes among others have a need to share patients’ records. Aside from the direction that all of these medical-related centers will have with a required connection to the insurance companies/agencies to speed up payments and their accuracy, the growing need is to have the ability to transfer patients’ medical files electronically anywhere in the world. As medical centers become more competitive, they will become worldwide centers of excellence for their given specialties. In turn then, their services will be marketed to the entire world population, becoming true global resources. The trend of converting hospitals into “paperless hospitals” is becoming one of the most important topics of the 1990s. In 1970, chartered by the National Academy of Sciences, the Institute of Medicine working under the Policy Matters for Public Health has actively pursued the creation of a computer-based record (CBR). In July of 1991 a book was published by the Institute of Medicine in regards to the CBR. The requirements to compile an all-digital medical record (ADMR)will require ways to combine data, graphics, voice, signals, and images, both clinical and document. The architecture that will accommodate all these forms of information for capturing, storing, communicating, and displaying is extremely complex. Some of the technologies involved include optical fibers, LANs, compact/optical disks, bedside terminals, medical image display stations, image diagnostic workstations, and picture archival and communications systems to name a few. The High Performance Computing and Communications Initiative (HPCCI) was signed into law in December of 1991. Although most of the emphasis for this initiative was from a research and academic sense, some Luis Kun Cedars-Sinai Medical Center Matthew F. Baretich University of Colorado
of the true practical values of these highways of information will occur at the clinical level. While advances are taking place in different parts of the world in fighting diseases such as cancer, AIDS, heart disease, cystic fibrosis, Alzheimers, Parkinsons, Gaucher's, and malignant hyperthermia, not sharing the knowledge learned by all the groups would be a terrible underutilization of extremely costly resources, causing duplication of effort and enormous waste of time and resources The four technologies that have been considered critical by the National Institutes of Health for the con years are molecular medicine, vaccine development, structural biology, and biotechnology. The four will greatly be affected by the HPCCI. Finally, the integration of all medical-related information will be the most complex ask that the healthcare arena will face this decade Clinical Information Standards One of the most demanding and key areas for successfully integrating the hospital information system(HIS) with the clinical information systems( CIS) from multiple clinical departments and/or clinical areas deals with clinical information standards. Two of the driving forces behind the automation of the patient record deal with national concerns related to healthcare costs and quality of healthcare. These concerns have generated demand for managed care. The automated patient record could then be one of the vehicles to achieve managed care. Clinical information standards are constantly evolving. They were developed(some are still in the process of development;e.g, IEEE/MIB P1073)by very different sets of requirements. What follows is a brief description and structure of most of these standards Communications Storage (e.g, HL/7, IEEE/MEDIX P1157, ANSI ASC X12, ACR/NEMA, IEEE/MIB P1073 The HL/7 standards group aimed to define vendor-independent communications standards among components of hospital information systems. The IEEE, ANSI, ACR/NEMA, and AsTM have been very active in creating standards through subcommittees from organizations within. As an example, ASTM has the following Health care Automation Committees(E31.XX): E31.10: Computer automation in the Hospital Pharmacy E31. 11: Data exchange standards for Clinical Laboratory results E31. 12: Medical Informatics E31. 13: Clinical Laboratory Systems E31. 14: Clinical Laboratory Instrument Interface E31. 15: Health Knowledge Representation The MEDIX mission was to establish a robust and flexible communications standard for the exchange of data between heterogeneous healthcare information systems. The MiB was created mainly to allow the exchange of data from medical instrumentation, e.g., monitoring devices and hospital information systems. Many of the manufacturers of these devices have proprietary hardware, e.g., buses and/or software, which complicates this exchange. Bedside terminals in the intensive care environment will benefit immensely from such a standard since most hospitals'ICUs and CCUs have many vendors equipment in their units. To effectively integrate and manage the data are major goals of the MIB. Classification/Reimbursement(e.g, ICD, DRG, SNOMED, CPT, DSM, RCS, UMLS) ICDs were originally used for public health morbidity statistics; now in the United States they are primarily used for reimbursement. Its structure is numbered classification of diseases grouped by anatomical areas. The RGs facilitate the definition of case-mix for hospital reimbursement. Its structure is multi-axial: severity of illness, prognosis, treatment difficulty, need for intervention, and resource intensity. SNOMED Provides description of pathological tests related to patient identification. It has four axes: function(primary symptoms) etiology(cause of disease), morphology(description of disease form), and topology(area of body ) CPT is primarily used for reimbursement and utilization review. It derives codes from specialty nomenclatures divided into chapters: systemic(medicine, anesthesia, etc. ) topological (cardiovascular, lymphatic, etc. ) and technological e 2000 by CRC Press LLC
© 2000 by CRC Press LLC of the true practical values of these highways of information will occur at the clinical level. While advances are taking place in different parts of the world in fighting diseases such as cancer, AIDS, heart disease, cystic fibrosis, Alzheimer’s, Parkinson’s, Gaucher’s, and malignant hyperthermia, not sharing the knowledge learned by all the groups would be a terrible underutilization of extremely costly resources, causing duplication of effort and enormous waste of time and resources. The four technologies that have been considered critical by the National Institutes of Health for the coming years are molecular medicine, vaccine development, structural biology, and biotechnology. The four will greatly be affected by the HPCCI. Finally, the integration of all medical-related information will be the most complex task that the healthcare arena will face this decade. Clinical Information Standards One of the most demanding and key areas for successfully integrating the hospital information system (HIS) with the clinical information systems (CIS) from multiple clinical departments and/or clinical areas deals with clinical information standards. Two of the driving forces behind the automation of the patient record deal with national concerns related to healthcare costs and quality of healthcare. These concerns have generated demand for managed care. The automated patient record could then be one of the vehicles to achieve managed care. Clinical information standards are constantly evolving. They were developed (some are still in the process of development; e.g., IEEE/MIB P1073) by very different sets of requirements. What follows is a brief description and structure of most of these standards. Communications/Storage (e.g., HL/7, IEEE/MEDIX P1157, ANSI ASC X12, ACR/NEMA, IEEE/MIB P1073) The HL/7 standards group aimed to define vendor-independent communications standards among components of hospital information systems. The IEEE, ANSI, ACR/NEMA, and ASTM have been very active in creating standards through subcommittees from organizations within. As an example, ASTM has the following Healthcare Automation Committees (E31.XX): • E31.10: Computer automation in the Hospital Pharmacy • E31.11: Data exchange standards for Clinical Laboratory results • E31.12: Medical Informatics • E31.13: Clinical Laboratory Systems • E31.14: Clinical Laboratory Instrument Interface • E31.15: Health Knowledge Representation The MEDIX mission was to establish a robust and flexible communications standard for the exchange of data between heterogeneous healthcare information systems. The MIB was created mainly to allow the exchange of data from medical instrumentation, e.g., monitoring devices and hospital information systems. Many of the manufacturers of these devices have proprietary hardware, e.g., buses and/or software, which complicates this exchange. Bedside terminals in the intensive care environment will benefit immensely from such a standard, since most hospitals’ ICUs and CCUs have many vendors’ equipment in their units. To effectively integrate and manage the data are major goals of the MIB. Classification/Reimbursement (e.g., ICD, DRG, SNOMED, CPT, DSM, RCS, UMLS) ICDs were originally used for public health morbidity statistics; now in the United States they are primarily used for reimbursement. Its structure is numbered classification of diseases grouped by anatomical areas. The DRGs facilitate the definition of case-mix for hospital reimbursement. Its structure is multi-axial: severity of illness, prognosis, treatment difficulty, need for intervention, and resource intensity. SNOMED provides description of pathological tests related to patient identification. It has four axes: function (primary symptoms), etiology (cause of disease), morphology (description of disease form), and topology (area of body). CPT is primarily used for reimbursement and utilization review. It derives codes from specialty nomenclatures divided into chapters: systemic (medicine, anesthesia, etc.), topological (cardiovascular, lymphatic, etc.), and technological
(radiology, laboratory, etc. ) DSM provides consistent abbreviations for prescription and administrative use. It facilitates psychiatric education and research. Its structure is multi-axial: clinical syndromes, developmental and personality disorders, physical disorder, severity psychological stresses, and global assessment functioning RCS is a comprehensive nomenclature and classification of medical terms for computerized records. UML facilitates the unification of clinical data classification systems into a single unified medical language system. It will also facilitate the creation of data into compatible automated patient record systems. Its structure reconciles clinical terminology, semantics, and formats of the major clinical coding and reference systems Knowledge (e.g, ARDEN SYNTAX The ARDEN SYNTAX is a standard for sharing medical knowledge bases in the form of medical logic modules (MLM). Its structure is derived from the HELP (LDS Hospital)and the CARE (Regenstrief MC)systems. The MLMs accommodate alerts, management critiques, therapy suggestions, diagnosis scoring, etc. Each MLM is limited to the knowledge to make a single decision. HCFA (e. g, UCDS, WARP, UHDDS) UCDS provides an electronic clinical data set that Medicare can use to perform clinical quality reviews. The quality evaluation is done by using algorithms related to surgical procedures, disease specific, organ specific discharge status and disposition, etc. The UCDS permits the hospital to enter the data into a personal computer then this information can be sent electronically to the HCFA. warP provides an epidemiologic approach to quality assurance. It hopes to overcome about 50% of ICD miscoding and its initial focus is on ambulatory chart review rather than real-time patient care. It is not a diagnostic or procedural classification system. It basically provides a model for encoding clinical information. It is an object-oriented case tool. UHDDS was created for studies on quality of care and fraud. It is also used for auditing Medicare and Medicaid subsystems. Bedside Terminals/point-of-Care Systems Patient information is generated on an ongoing basis, wherever the patient may be. Almost two decades ago with the creation of the first programmable calculators, a trend started in terms of calculating hemodynamic variables in the OR, etc. This approach was improved with the creation of personal computers, ending with the development of what are now called bedside terminals. Companies such as Clinicom, Emtek, Hewlett Packard, Hospitronics, and Spacelabs offer systems that can go from doing simply patient monitoring, to a complete data acquisition, data management, and data analysis system that incorporates in some cases diagnosis and treatment therapy. From the patients' point of view, it is critical to integrate their demographic information with their clinical data. Usually the HIS contains all the ADT, orders, laboratory, pharmacy, etc. while the CIS may be more of a departmental system such as ICU/CCU, which contains hemodynamic variables, i. e, blood pressure, stroke volume, heart rate, etc. Both systems need to coexist. Point-of-care systems, many times known as bedside terminals, include both general med/surgery and the ICU/CCU type. The general type include functions such as patient assessment, nursing diagnosis, patient care plans, kardex, discharge planning, discharge summary medication administration record, I/O, vital signs, activities of daily living, patient classification/acuity, etc. The ICU/CCU systems in addition contain information regarding drug administration, fluid analysis, hemodynamic lysis (i.e, blood gas report, ECG, blood pressures, pulse oximeters, cardiac output), respiratory analysi (i.e, ventilator data, O /CO, analyzer), and real-time monitoring. Today's trends are incorporating imaging devices in both at the regular nursing stations, at the operating rooms, and at the recovery room/ICU/CCU. The motivation is to incorporate all patients' information and have it available wherever they may be. As a atient moves from a regular bed to the OR, back to an ICU, and later to a regular nursing station, the electronic record follows the patient. The one big difference with paper charts is that the electronic record can be shared simultaneously within and outside the institution Having the ability to look at electronic images in all of these locations not only opens the doors for consultation within the institution but also with outside institutions and/or expert individuals e 2000 by CRC Press LLC
© 2000 by CRC Press LLC (radiology, laboratory, etc.). DSM provides consistent abbreviations for prescription and administrative use. It facilitates psychiatric education and research. Its structure is multi-axial: clinical syndromes, developmental and personality disorders, physical disorder, severity psychological stresses, and global assessment functioning. RCS is a comprehensive nomenclature and classification of medical terms for computerized records. UMLS facilitates the unification of clinical data classification systems into a single unified medical language system. It will also facilitate the creation of data into compatible automated patient record systems. Its structure reconciles clinical terminology, semantics, and formats of the major clinical coding and reference systems. Knowledge (e.g., ARDEN SYNTAX) The ARDEN SYNTAX is a standard for sharing medical knowledge bases in the form of medical logic modules (MLM). Its structure is derived from the HELP (LDS Hospital) and the CARE (Regenstrief MC) systems. The MLMs accommodate alerts, management critiques, therapy suggestions, diagnosis scoring, etc. Each MLM is limited to the knowledge to make a single decision. HCFA (e.g., UCDS, WARP, UHDDS) UCDS provides an electronic clinical data set that Medicare can use to perform clinical quality reviews. The quality evaluation is done by using algorithms related to surgical procedures, disease specific, organ specific, discharge status and disposition, etc. The UCDS permits the hospital to enter the data into a personal computer; then this information can be sent electronically to the HCFA. WARP provides an epidemiologic approach to quality assurance. It hopes to overcome about 50% of ICD miscoding and its initial focus is on ambulatory chart review rather than real-time patient care. It is not a diagnostic or procedural classification system. It basically provides a model for encoding clinical information. It is an object-oriented case tool. UHDDS was created for studies on quality of care and fraud. It is also used for auditing Medicare and Medicaid subsystems. Bedside Terminals/Point-of-Care Systems Patient information is generated on an ongoing basis, wherever the patient may be. Almost two decades ago with the creation of the first programmable calculators, a trend started in terms of calculating hemodynamic variables in the OR, etc. This approach was improved with the creation of personal computers, ending with the development of what are now called bedside terminals. Companies such as Clinicom, Emtek, HewlettPackard, Hospitronics, and Spacelabs offer systems that can go from doing simply patient monitoring, to a complete data acquisition, data management, and data analysis system that incorporates in some cases diagnosis and treatment therapy. From the patients’ point of view, it is critical to integrate their demographic information with their clinical data. Usually the HIS contains all the ADT, orders, laboratory, pharmacy, etc. while the CIS may be more of a departmental system such as ICU/CCU, which contains hemodynamic variables, i.e., blood pressure, stroke volume, heart rate, etc. Both systems need to coexist. Point-of-care systems, many times known as bedside terminals, include both general med/surgery and the ICU/CCU type. The general type include functions such as patient assessment, nursing diagnosis, patient care plans, kardex, discharge planning, discharge summary, medication administration record, I/O, vital signs, activities of daily living, patient classification/acuity, etc. The ICU/CCU systems in addition contain information regarding drug administration, fluid analysis, hemodynamic analysis (i.e., blood gas report, ECG, blood pressures, pulse oximeters, cardiac output), respiratory analysis (i.e., ventilator data, O2/CO2 analyzer), and real-time monitoring. Today’s trends are incorporating imaging devices in both at the regular nursing stations, at the operating rooms, and at the recovery room/ICU/CCU. The motivation is to incorporate all patients’ information and have it available wherever they may be. As a patient moves from a regular bed to the OR, back to an ICU, and later to a regular nursing station, the electronic record follows the patient. The one big difference with paper charts is that the electronic record can be shared simultaneously within and outside the institution. Having the ability to look at electronic images in all of these locations not only opens the doors for consultation within the institution but also with outside institutions and/or expert individuals
Care HIS Graphics Intensive Care Bedside Terminal Aerospace Medicine Occupational Med Cardiovascular Disease Orthopaedic Surgery File Serve Child Psychiatry Otorhinolaryngology Dermatolog Diagnostic Radiology Pediatric Allergy Emergency Medicine Pediatric Cardiology Public Health Physical Med g logy Rehabilitation General rgery e General Surgery Radiology Home AdmissionsNeurological Surger Urological su FIGURE 117.1 An example of medical systems integration Imaging and the CIs Imaging plays two very important roles within the context of a computer-based record (CBR).Document imaging allows for all those records that exist today in storage for the medical records departments to be scanned and incorporated electronically with the rest of the patient's current records existing in the HIS and CIS. The second role is from the perspective of clinical images. Most imaging experts will call this PACS, which stands for picture archival and communications system and is mostly associated with the Radiology Department of the hospital. We can view clinical images as a form of data which can be generated in any department. Some of these typical clinical departments utilizing clinical images are radiology, cardiology(e.g, echocar diography, fluoroscopic techniques, cine cameras, 3D modeling, gamma cameras), orthopedic surgery, plastie surgery,obstetrics/gynecology, laboratories(e.g, genetics, chromosome analysis, cytology, hematology, clinical mistry, pathology, histology, electron microscope), maxillofacial clinics, sports medicine, and oncology(e.g radiation therapy, chemotherapy), emergency rooms, intensive care units, etc. There are five imaging modalities: x-ray, magnetic resonance imaging(MRI), computer tomography (Ct) nuclear medicine(NM), and ultrasound(US). These modalities create images which are very different not only in medical terms but in their size and content As a result there are three main areas under pacs which are critical in succeeding with such systems: communications (ie, network, transmission protocol, and image format), archiving (i. e, database and storage media), and image processing (i.e, display, user interface, and IP algorithms Systems Integration As an example of systems integration in the emergency care environment(see Fig 117.1),from an information- flow point of view we see the following: e 2000 by CRC Press LLC
© 2000 by CRC Press LLC Imaging and the CIS Imaging plays two very important roles within the context of a computer-based record (CBR). Document imaging allows for all those records that exist today in storage for the medical records departments to be scanned and incorporated electronically with the rest of the patient’s current records existing in the HIS and CIS. The second role is from the perspective of clinical images. Most imaging experts will call this PACS, which stands for picture archival and communications system and is mostly associated with the Radiology Department of the hospital. We can view clinical images as a form of data which can be generated in any department. Some of these typical clinical departments utilizing clinical images are radiology, cardiology (e.g., echocardiography, fluoroscopic techniques, cine cameras, 3D modeling, gamma cameras), orthopedic surgery, plastic surgery, obstetrics/gynecology, laboratories (e.g., genetics, chromosome analysis, cytology, hematology, clinical chemistry, pathology, histology, electron microscope), maxillofacial clinics, sports medicine, and oncology (e.g., radiation therapy, chemotherapy), emergency rooms, intensive care units, etc. There are five imaging modalities: x-ray, magnetic resonance imaging (MRI), computer tomography (CT), nuclear medicine (NM), and ultrasound (US). These modalities create images which are very different not only in medical terms but in their size and content. As a result, there are three main areas under PACS which are critical in succeeding with such systems: communications (i.e., network, transmission protocol, and image format), archiving (i.e., database and storage media), and image processing (i.e., display, user interface, and IP algorithms). Systems Integration As an example of systems integration in the emergency care environment (see Fig. 117.1), from an information- flow point of view we see the following: FIGURE 117.1 An example of medical systems integration
1. Information coming and going to the HIS, e.g., laboratory, pharmacy, orders, etc. 2. Information going to outpatient clinics for referring services, admissions to the hospital, or even to the patients physician at home. 3. In the emergency room, the utilization of an intensive care type of bedside terminal allowing data ollection, analysis and management, and also the ability to view clinical images in the ER. rom a consulting point of view, the whole electronic patient record, under an integrated diagnostic system,allows for any(department)consulting physician within or outside the hospital to review the case. Smart/Optical Card Smart/optical cards provide a wide range of applications in the medical field. The patient, the provider (e.g physician, dentist, etc. ) the hospital, and the insurer can all benefit from such a card. The card will eventually ontain all data forms-voice, text, graphics, clinical images, document images, signals, and data values collected from medical instrumentation. Besides patient identification/demographics, medical history, medications, aller- es, and insurance verification, the system could contain the patient's picture, fingerprint, digital signature, voice signature, and even genetic/blood information for security reasons The patient is admitted and treatment is provided more quickly, historical information is more accurate, and personal physicians and specialists can be consulted more quickly. Less testing may be a direct result, and faster diagnosis is accomplished. Since information needs to be entered only once, patients do not need to rely on their memory, particularly in emergency situations. The hospital identifies the patient and accesses all the medical records information from multiple departments more quickly. It needs fewer staff to find records from the hospital/clinics(even from other institutions), and this could reduce the length of stay The provider is better informed for a quicker diagnosis by getting all the available history at admission and can consult with the patients personal physician and specialist by having their respective phone numbers. All prior records from the same or a different set of institutions coexist in the card. It also can reduce exposure to malpractice The insurer reduces fraudulent claims, reduces costs for data entry, and has more complete and accurate claims data. Also, by eliminating redundant tests costs are reduced. Most of the cards can be classified into five groups by the type of technologies used: microfilm, magnetic trip, softstrip, chip, and laser/optical Microfilm is hard to change and can be damaged by both temperature and humidity. Magnetic strip contains little information, approximately 2K, and can be destroyed by electric and magnetic fields. The softstrip, because it is laser printed and optically read, is difficult to change information on. The chip card has only up to 10K of storage and is very expensive. Finally, the laser/optical card allows for approximately 1000 typed pages or approximately 4 Mb of memory and requires a read/write device Some of the complexities that are incorporated by using these types of technologies are associated with the access to the information. For someone to be able to either"read"and/or" write"in the card, it must possess technologies compatible with the ones where the information was created. It is a fundamental principle then that a set of international standards will be created so that any hospital that requires access to the card information can do so. Already the International Patient Cards Standards Council, the Health Industry Business Communications Council(HIBCC), and the Smart Card Applications and Technology(SCAT)have been created. These groups, among others, are working towards the goal of an international set of standards There is a large set of companies that are already marketing different types of card examples of proje Affiliated Healthcare in Princeton, New Jersey, which maintains a Health Summary Database with a Smart Card CentraHealth, a Florida hospital network with about 12K users Clinicard, a subscription service which provides a softstrip, 3K, PC DOS card that folds to a business Drexler Laser Card from Mountain View, California, which has 4 1-Mb card being tested by both British Telecom with a hospital group specializing in obstetric patients and Baylor College of Medicine in e 2000 by CRC Press LLC
© 2000 by CRC Press LLC 1. Information coming and going to the HIS, e.g., laboratory, pharmacy, orders, etc. 2. Information going to outpatient clinics for referring services, admissions to the hospital, or even to the patient’s physician at home. 3. In the emergency room, the utilization of an intensive care type of bedside terminal allowing data collection, analysis and management, and also the ability to view clinical images in the ER. 4. From a consulting point of view, the whole electronic patient record, under an integrated diagnostic system, allows for any (department) consulting physician within or outside the hospital to review the case. Smart/Optical Cards Smart/optical cards provide a wide range of applications in the medical field. The patient, the provider (e.g., physician, dentist, etc.), the hospital, and the insurer can all benefit from such a card. The card will eventually contain all data forms—voice, text, graphics, clinical images, document images, signals, and data values collected from medical instrumentation. Besides patient identification/demographics, medical history, medications, allergies, and insurance verification, the system could contain the patient’s picture, fingerprint, digital signature, voice signature, and even genetic/blood information for security reasons. The patient is admitted and treatment is provided more quickly, historical information is more accurate, and personal physicians and specialists can be consulted more quickly. Less testing may be a direct result, and faster diagnosis is accomplished. Since information needs to be entered only once, patients do not need to rely on their memory, particularly in emergency situations. The hospital identifies the patient and accesses all the medical records information from multiple departments more quickly. It needs fewer staff to find records from the hospital/clinics (even from other institutions), and this could reduce the length of stay. The provider is better informed for a quicker diagnosis by getting all the available history at admission and can consult with the patient’s personal physician and specialist by having their respective phone numbers. All prior records from the same or a different set of institutions coexist in the card. It also can reduce exposure to malpractice. The insurer reduces fraudulent claims, reduces costs for data entry, and has more complete and accurate claims data. Also, by eliminating redundant tests costs are reduced. Most of the cards can be classified into five groups by the type of technologies used: microfilm, magnetic strip, softstrip, chip, and laser/optical. Microfilm is hard to change and can be damaged by both temperature and humidity. Magnetic strip contains little information, approximately 2K, and can be destroyed by electric and magnetic fields. The softstrip, because it is laser printed and optically read, is difficult to change information on. The chip card has only up to 10K of storage and is very expensive. Finally, the laser/optical card allows for approximately 1000 typed pages or approximately 4 Mb of memory and requires a read/write device. Some of the complexities that are incorporated by using these types of technologies are associated with the access to the information. For someone to be able to either “read” and/or “write” in the card, it must possess technologies compatible with the ones where the information was created. It is a fundamental principle then that a set of international standards will be created so that any hospital that requires access to the card information can do so. Already the International Patient Cards Standards Council, the Health Industry Business Communications Council (HIBCC), and the Smart Card Applications and Technology (SCAT) have been created. These groups, among others, are working towards the goal of an international set of standards. There is a large set of companies that are already marketing different types of card technologies. Some examples of projects and/or vendors include: • Affiliated Healthcare in Princeton, New Jersey, which maintains a Health Summary Database with a Smart Card. • CentraHealth, a Florida hospital network with about 12K users. • Clinicard, a subscription service which provides a softstrip, 3K, PC DOS card that folds to a business card size. • Drexler LaserCard from Mountain View, California, which has 4.1-Mb card being tested by both British Telecom with a hospital group specializing in obstetric patients and Baylor College of Medicine in Houston, Texas
Eltrax in St Paul, Minnesota, which is associated with several HIS manufacturers(Spectrum, McDonald Douglas, SMS, and Meditech)and provides a magnetic strip card with about 900-character capacity IMSG/INFODYNE from Englewood, Colorado, which has a medical information card on magnetic strip carrying up to 600 characters. IntelliScan from American Medical Data Corp in Atlanta, Georgia, which has information stored as 350 characters of readable text printed on the top of the card and up to 850 characters of detailed medical information optically encoded at the bottom. It is being used by hospitals in both Texas and Mississippi The cards are customized to each hospitals database Lifecard, early pilot(1985)card for electronic claims provided by Blue Cross/Shield of Maryland Medfirst credit card, combining both medical information and financial credit, in test by Humana and Discovery Card. Medi-Card, a chip card from MediData Systems in Allston, Massachusetts. MedKey, from Biloxi Regional Medical Center, Biloxi, Mississippi Medical Information Systems, in St. Louis, Missouri, which has a microfilm card that can contain up to 18 pages of information, including signals, text, images, data, and color photos Ulticard, a 64K RAM memory chip in a credit card sized pack being tested in Houston at Baylor and Methodist hospitals. Some of the cards are being tested in different countries. Sweden, the leader for about 20 years, has been ing a patient card which is issued at birth by the government together with an ID number. Sweden has a medicine program and it has been in their best interest lards so that the information can be accessed by every institution in the country. Belgium, Canada, france and Switzerland all have several systems on trial acronyms ACR/NEMA: American College of Radiology/National Equipment Manufacturers Association ANSI ASC X12: American National Standards Institute Accredited Standards Committee ARDEN SYNTAX: Syntax for Medical Logic Module ASTM: American Society for Testing and Materials CIS: Clinical Information System CPT: Current Procedural Terminology DRG: elated Group DSM: Diagnostic and Statistical Manual of Mental Disorders EDI: Electronic Data Interchange HCFA: Healthcare Financing Administration HIS: Hospital Information System HL/7: Health Level/7 ICD: International Classification of diseases IDS: Integrated Diagnostic System IEEE: Institute of Electrical and Electronics Engineers IEEE/MEDIX P1157: Medical Data Interchange IEEE/MIB P1073: Medical Information Bus OSI: Open Systems Interconnection RCS: Read Classification System NOMED: Systemized Nomenclature of Medicine UCDS: Uniform Clinical Data Set UHDDS: Uniform Hospital Discharge Data Set UMLS: Unified Medical Language System WARP: Wisconsin Ambulatory Review Project e 2000 by CRC Press LLC
© 2000 by CRC Press LLC • Eltrax in St. Paul, Minnesota, which is associated with several HIS manufacturers (Spectrum, McDonald Douglas, SMS, and Meditech) and provides a magnetic strip card with about 900-character capacity. • IMSG/INFODYNE from Englewood, Colorado, which has a medical information card on magnetic strip carrying up to 600 characters. • IntelliScan from American Medical Data Corp. in Atlanta, Georgia, which has information stored as 350 characters of readable text printed on the top of the card and up to 850 characters of detailed medical information optically encoded at the bottom. It is being used by hospitals in both Texas and Mississippi. The cards are customized to each hospital’s database. • Lifecard, early pilot (1985) card for electronic claims provided by Blue Cross/Shield of Maryland. • Medfirst credit card, combining both medical information and financial credit, in test by Humana and Discovery Card. • Medi-Card, a chip card from MediData Systems in Allston, Massachusetts. • MedKey, from Biloxi Regional Medical Center, Biloxi, Mississippi. • Medical Information Systems, in St. Louis, Missouri, which has a microfilm card that can contain up to 18 pages of information, including signals, text, images, data, and color photos. • Ulticard, a 64K RAM memory chip in a credit card sized pack being tested in Houston at Baylor and Methodist hospitals. Some of the cards are being tested in different countries. Sweden, the leader for about 20 years, has been using a patient card which is issued at birth by the government together with an ID number. Sweden has a socialized medicine program and it has been in their best interest to develop uniform standards so that the information can be accessed by every institution in the country. Belgium, Canada, France, Great Britain, Spain, and Switzerland all have several systems on trial. Acronyms ACR/NEMA: American College of Radiology/National Equipment Manufacturers Association ANSI ASC X12: American National Standards Institute Accredited Standards Committee ARDEN SYNTAX: Syntax for Medical Logic Modules ASTM: American Society for Testing and Materials CIS: Clinical Information System CPT: Current Procedural Terminology DRG: Diagnostic Related Group DSM: Diagnostic and Statistical Manual of Mental Disorders EDI: Electronic Data Interchange HCFA: Healthcare Financing Administration HIS: Hospital Information System HL/7: Health Level/7 ICD: International Classification of Diseases IDS: Integrated Diagnostic System IEEE: Institute of Electrical and Electronics Engineers IEEE/MEDIX P1157: Medical Data Interchange IEEE/MIB P1073: Medical Information Bus OSI: Open Systems Interconnection RCS: Read Classification System SNOMED: Systemized Nomenclature of Medicine UCDS: Uniform Clinical Data Set UHDDS: Uniform Hospital Discharge Data Set UMLS: Unified Medical Language System WARP: Wisconsin Ambulatory Review Project
Related Topics 97.1 Introduction. 117.2 Hospital Information Systems References Bedside Terminals/Point-of-Care W. Donovan and S Corrales, The Book on Bedside Computing, Long Beach, Calif. Inside Healthcare Computing, L. Kun,The use of a personal computer for patient-condition-treatment in a CUU/ICU environment,"IEEE Transactions on Biomedical Engineering, vol. BME-30, no. 8, August 1983. L. Kun,"Rapid assessment of hemodynamic cardiorespiratory function for the critically ill with a personal computer,"IEEE Transactions on Biomedical Engineering, vol. BME-30, no 8, August 1983. Rockville, md. National D. OBoyle, G. Feiherr, and R. Gough, The Buyer's Guide to Bedside Computer Systems, Rockville, Report of Computers Health, 1 M.M. Shabot et al.,"Rapid bedside computation of cardiorespiratory variables with a programmable calculator, Critical Care Med., vol. 5, P. 105, 1977 Classification Systems Standards C. Chute, Tutorial 19: Clinical data representation, "in Proceedings of SCAMC 91, November 1991 B. Humphreys, Building the Unified Medical Language System, Bethseda, Md. National Library of Medicine, 1989 Communications Standards J. Harrington, IEEE/EMBS P1158,"Medical Data Interchange(MEDIX) overview and status report, in Pro ceedings of SCAMC 90, November 1990 National Electrical Manufacturers Association, " Digital Imaging and Communications, " ACR-NEMA Standards Publication no, 300-1988.1 R E. Norden-Paul, IEEE Proposed Standard 1073, Medical Information Bus: An Introduction and Progress Report, in Proceedings of the 9th Annual Conference of the IEEE-EMBS, vol. 2, MIB Symposium, Boston Pp.1209-1211,1987 Knowledge Base Standards The ARDEN SYNTAX for medical logic modules, " in Proceedings of SCAMC 90, November 1990 Emerging standards for medical logic, "in Proceedings of SCAMC 90, November 1990 Clinical Imaging/PACS Y. Kim and E.A. Spelman, Eds,"Images of the twenty-first century, "in Proceedings of the Annual International IEEE-EMBS, vol. 11, part 2, track 2, Imaging, pp. 345-630; Track 23, Picture Archiving and cations Systems, pp. 775-793, 1989 L Kun,"Imaging and the clinical information system, in Proceedings of 91 International Workshop on Medical Imaging, Korea Institute of Science and Technology, Seoul, Korea. Computerized Medical Record M. Ball and M. Collin, Eds, Aspects of the Computer-Based Patient Record, New York: Springer-Verlag, 1992 J. Blair, "Overview of clinical information representation and standard organization, " in Proceedings of the Fall 92 ECHO Meeting, Palm Beach, Calif, 1992. e 2000 by CRC Press LLC
© 2000 by CRC Press LLC Related Topics 97.1 Introduction • 117.2 Hospital Information Systems References Bedside Terminals/Point-of-Care W. Donovan and S. Corrales, The Book on Bedside Computing, Long Beach, Calif.: Inside Healthcare Computing, 1991. L. Kun, “The use of a personal computer for patient-condition-treatment in a CUU/ICU environment,” IEEE Transactions on Biomedical Engineering, vol. BME-30, no. 8, August 1983. L. Kun, “Rapid assessment of hemodynamic cardiorespiratory function for the critically ill with a personal computer,” IEEE Transactions on Biomedical Engineering, vol. BME-30, no. 8, August 1983. D. O’Boyle, G. Feiherr, and R. Gough, The Buyer’s Guide to Bedside Computer Systems, Rockville, Md.: National Report of Computers & Health, 1991. M.M. Shabot et al., “Rapid bedside computation of cardiorespiratory variables with a programmable calculator,” Critical Care Med., vol. 5, p. 105, 1977. Classification Systems Standards C. Chute, “Tutorial 19: Clinical data representation,” in Proceedings of SCAMC 91, November 1991. B. Humphreys, Building the Unified Medical Language System, Bethseda, Md.: National Library of Medicine, 1989. Communications Standards J. Harrington, IEEE/EMBS P1158, “Medical Data Interchange (MEDIX) overview and status report,” in Proceedings of SCAMC 90, November 1990. National Electrical Manufacturers Association, “Digital Imaging and Communications,” ACR-NEMA Standards Publication No. 300-1988, 1988. R.E. Norden-Paul, IEEE Proposed Standard 1073, “Medical Information Bus: An Introduction and Progress Report,” in Proceedings of the 9th Annual Conference of the IEEE-EMBS, vol. 2, MIB Symposium, Boston, pp. 1209–1211, 1987. Knowledge Base Standards “The ARDEN SYNTAX for medical logic modules,” in Proceedings of SCAMC 90, November 1990. “Emerging standards for medical logic,” in Proceedings of SCAMC 90, November 1990. Clinical Imaging/PACS Y. Kim and F.A. Spelman, Eds., “Images of the twenty-first century,” in Proceedings of the Annual International IEEE-EMBS, vol. 11, part 2, track 2, Imaging, pp. 345–630; Track 23, Picture Archiving and Communications Systems, pp. 775–793, 1989. L. Kun, “Imaging and the clinical information system,” in Proceedings of ’91 International Workshop on Medical Imaging, Korea Institute of Science and Technology, Seoul, Korea. Computerized Medical Record M. Ball and M. Collin, Eds., Aspects of the Computer-Based Patient Record, New York: Springer-Verlag, 1992. J. Blair, “Overview of clinical information representation and standard organization,” in Proceedings of the Fall 92 ECHO Meeting, Palm Beach, Calif., 1992
Institute of Medicine, Computer-Based Patient Record, Washington, D. C. National Academy Press, 1991 C.J. McDonald et al.,The benefits of automated medical record systems for ambulatory care, "in Proceedings of the Computer Applications in Medical Care Conference, New York: IEEE Computer Society, Pp. 157-171 October 1986 W.W. Stead et al., Practicing nephrology with a computerized medical record, Kidney Int, vol. 24, Pp 446-454 Q. E. Whiting-OKeefe et al., "A computerized summary medical record system can produce more information than the standard medical record, "in Proceedings of MedInfo 86, Washington, D. C, 1986 High-Performance Computing and Communications, (HPCC D.A. Bromley, The Federal High-Performance Computing Program, Washington, D. C. Executive Office of the President, Office of Science and Technology Policy, 1989 Tational High-Performance Computer Technology Act, "Congressional Record, U.S. Senate 101st Congress, First Session 5/18/89, Washington, D.C. Smart/Optical Cards Handbook of Optical Memory Systems. Bi-monthly updating service. Boston: Medical Records Institute. Proceedings of the 13th Annual International Conference IEEE/EMBS, Track 21: Session 5, Medical Informatics V: Optical and Smart Cards, Orlando, Fla, Pp. 1387-1392, October 1991. 1989 Smart Card Industry Directory, Palo Alto, Calif. Palo Alto Management Inc., 1989 117.2 Hospital Information Systems Matthew e. baretich What does an electrical engineer need to know to be part of a team designing and implementing a hospital information system? For the most part, the necessary skills are those required to design and implement any comprehensive information system in a complex organization. Hospitals do, however, have unique characte istics that must be taken into account. These characteristics are described in the following pages. The Clinical environment Hospitals are, indeed, complex organizations. They perform a vital function(patient care) but are subject to trict regulation and operate under severe financial constraints. Quality of patient care is the highest value, but a competitive marketplace demands efficient operation. Hospital information systems range from nonexistent Hospitals are highly professionalized. Each professional group has a particular area of expertise and a unique perspective regarding the healthcare delivery system. Hospital administrators are much like administrators of ther organizations. Recent graduates essentially have standard Master of Business Administration) degrees with some extent of healthcare specialization. However, many administrators in positions of authority from schools than with business schools Hospitals also have large clinical staffs which include nurses and technologists(who are hospital employees) and medical doctors(who are usually not hospital employees). Clinicians are educated in the biological and medical sciences, and their preparation generally includes a large component of practical experience in the pital as well as theoretical study in the classroom. As hospital employees, nurses and technologists(respi- ratory, laboratory, etc )are part of the administrative structure of the hospital Medical doctors(physicians and geons),on the other hand, are part of a separate medical staff structure that is largely independent of the hospitals administrative structure. However, medical doctors control the admission and discharge of the hospitals patients, and many hospital activities are the result of medical orders for patient services e 2000 by CRC Press LLC
© 2000 by CRC Press LLC Institute of Medicine, Computer-Based Patient Record, Washington, D.C.: National Academy Press, 1991. C.J. McDonald et al., “The benefits of automated medical record systems for ambulatory care,” in Proceedings of the Computer Applications in Medical Care Conference, New York: IEEE Computer Society, pp. 157–171, October 1986. W.W. Stead et al., “Practicing nephrology with a computerized medical record,” Kidney Int., vol. 24, pp. 446–454, 1983. Q.E. Whiting-O’Keefe et al., “A computerized summary medical record system can produce more information than the standard medical record,” in Proceedings of MedInfo ’86, Washington, D.C., 1986. High-Performance Computing and Communications, (HPCC) D.A. Bromley, “The Federal High-Performance Computing Program,” Washington, D.C.: Executive Office of the President, Office of Science and Technology Policy, 1989. “National High-Performance Computer Technology Act,” Congressional Record, U.S. Senate 101st Congress, First Session 5/18/89, Washington, D.C. Smart/Optical Cards Handbook of Optical Memory Systems. Bi-monthly updating service. Boston: Medical Records Institute. Proceedings of the 13th Annual International Conference IEEE/EMBS, Track 21: Session 5, Medical Informatics V: Optical and Smart Cards, Orlando, Fla., pp. 1387–1392, October 1991. 1989 Smart Card Industry Directory, Palo Alto, Calif.: Palo Alto Management Inc., 1989. 117.2 Hospital Information Systems Matthew F. Baretich What does an electrical engineer need to know to be part of a team designing and implementing a hospital information system? For the most part, the necessary skills are those required to design and implement any comprehensive information system in a complex organization. Hospitals do, however, have unique characteristics that must be taken into account. These characteristics are described in the following pages. The Clinical Environment Hospitals are, indeed, complex organizations. They perform a vital function (patient care) but are subject to strict regulation and operate under severe financial constraints. Quality of patient care is the highest value, but a competitive marketplace demands efficient operation. Hospital information systems range from nonexistent to antique to state-of-the-art. Hospitals are highly professionalized. Each professional group has a particular area of expertise and a unique perspective regarding the healthcare delivery system. Hospital administrators are much like administrators of other organizations. Recent graduates essentially have standard MBA (Master of Business Administration) degrees with some extent of healthcare specialization. However, many administrators in positions of authority received MHA (Master of Hospital Administration) degrees from programs more closely affiliated with medical schools than with business schools. Hospitals also have large clinical staffs which include nurses and technologists (who are hospital employees) and medical doctors (who are usually not hospital employees). Clinicians are educated in the biological and medical sciences, and their preparation generally includes a large component of practical experience in the hospital as well as theoretical study in the classroom. As hospital employees, nurses and technologists (respiratory, laboratory, etc.) are part of the administrative structure of the hospital. Medical doctors (physicians and surgeons), on the other hand, are part of a separate medical staff structure that is largely independent of the hospital’s administrative structure. However, medical doctors control the admission and discharge of the hospital’s patients, and many hospital activities are the result of medical orders for patient services
The number of hospital employees with an engineering background is limited. For the electrical engineer who is involved in the implementation of a hospital information system, hospital-based technical support may include an information systems department and a clinical engineering (or biomedical engineering) department. The following aspects of the healthcare delivery system are worthy of study by an electrical engineer working in the clinical environment: The healthcare delivery system in the United States Williams and Torrens, 1984 The organizational structure of hospitals[Goldberg and Buttaro, 1990] The characteristics of hospital information systems [Austin, 1988; Minard, 1991] With this background information the electrical engineer will be better prepared to translate the concerns of hospital administrators and clinicians into the technical specifications of the hospital information system Healthcare Codes and Standards The healthcare delivery system is a highly regulated industry. Numerous governmental and nongovernmental organizations have established codes and standards intended to promote safe and effective patient care. although there can be significant differences in the regulatory environment from one hospital to another, the major codes and standards are relatively uniform The National Electrical Code(NFPA 70), promulgated by the National Fire Protection Association(NFPA Quincy, Massachusetts)applies to hospitals. Specifically, Article 517 deals with "Health Care Facilities. A more cused document, however, is the Standard for Health Care Facilities(NFPA 99). The most accessible format for this information is the NFPas Health Care Facilities Handbook Klein, 1990 which includes the full text of NFPA 99 as well as interpretive and explanatory material. Many of the healthcare-related provisions of the electrical code are based on two concerns. First, many patients in surgery and intensive care depend on electrical equipment for life support. Such equipment ranges from heart-lung bypass devices to mechanical ventilators. Therefore, much attention is devoted to ensuring the availability of electrical power in the event that the primary power distribution system fails. a hospital infor mation system that provides life-support functions may be subject to these provisions Second, because of the use of invasive medical procedures, many patients are considered to be electrically susceptible. Under certain conditions, electrical currents on the order of microamperes can cause ventricular orillation, a potentially fatal disruption of normal cardiac function. Therefore, the NFPA and other organi zations have established strict standards for grounding, "leakage"current, and other electrical parameters. These standards apply to devices and cabling in patient-care locations of the hospital. The Joint Commission on Accreditation of Healthcare Organizations( Chicago, Illinois)is another major source of standards affecting hospitals. The JCAHO's Accreditation Manual for Hospitals [JCAHO, 1993]covers the entire spectrum of hospital activities. Pursuit of JCAHO accreditation is voluntary but, in practice, essentially all hospitals seek accreditation to ensure eligibility for reimbursement under certain governmental programs At present, JCAHO standards include little reference to information systems. However, this is expected to change and, therefore, familiarity with the latest edition of the Accreditation Manual for Hospitals is advisable Another standard unique to the healthcare system is Health Level 7(HL7) which is a data communications protocol intended to facilitate the interfacing of various components in a hospital information system Walker, 1989]. These components range from accounting systems(financial data)to clinical laboratory information systems(laboratory test results)to medical records systems(documentation of patient care services)to patient data management systems(physiological data). In the recent past, each such component was independent and generally incompatible with other components. However, to achieve high quality in patient care at the lowest cost, both administrators and clinicians need integrated, comprehensive access to a wide variety of information HL is an attempt to specify the types of data(and their formats)to be shared within a hospital information system. For example, if all components of the system use a common format for a patient's name, then possible for a single database query to gather all data regarding that patient. This also allows automation of certain activities such as billing(through the accounting system) for laboratory tests ordered by clinicians (through the clinical laboratory system). Unfortunately, HL7 has not achieved its promise but it does represent a significant step away from the chaotic past[Bond et al, 1990] e 2000 by CRC Press LLC
© 2000 by CRC Press LLC The number of hospital employees with an engineering background is limited. For the electrical engineer who is involved in the implementation of a hospital information system, hospital-based technical support may include an information systems department and a clinical engineering (or biomedical engineering) department. The following aspects of the healthcare delivery system are worthy of study by an electrical engineer working in the clinical environment: • The healthcare delivery system in the United States [Williams and Torrens, 1984] • The organizational structure of hospitals [Goldberg and Buttaro, 1990] • The characteristics of hospital information systems [Austin, 1988; Minard, 1991] With this background information the electrical engineer will be better prepared to translate the concerns of hospital administrators and clinicians into the technical specifications of the hospital information system. Healthcare Codes and Standards The healthcare delivery system is a highly regulated industry. Numerous governmental and nongovernmental organizations have established codes and standards intended to promote safe and effective patient care.Although there can be significant differences in the regulatory environment from one hospital to another, the major codes and standards are relatively uniform. The National Electrical Code (NFPA 70), promulgated by the National Fire Protection Association (NFPA: Quincy, Massachusetts) applies to hospitals. Specifically, Article 517 deals with “Health Care Facilities.” A more focused document, however, is the Standard for Health Care Facilities (NFPA 99). The most accessible format for this information is the NFPA’s Health Care Facilities Handbook [Klein, 1990] which includes the full text of NFPA 99 as well as interpretive and explanatory material. Many of the healthcare-related provisions of the electrical code are based on two concerns. First, many patients in surgery and intensive care depend on electrical equipment for life support. Such equipment ranges from heart-lung bypass devices to mechanical ventilators. Therefore, much attention is devoted to ensuring the availability of electrical power in the event that the primary power distribution system fails. A hospital information system that provides life-support functions may be subject to these provisions. Second, because of the use of invasive medical procedures, many patients are considered to be “electrically susceptible.” Under certain conditions, electrical currents on the order of microamperes can cause ventricular fibrillation, a potentially fatal disruption of normal cardiac function. Therefore, the NFPA and other organizations have established strict standards for grounding, “leakage” current, and other electrical parameters. These standards apply to devices and cabling in patient-care locations of the hospital. The Joint Commission on Accreditation of Healthcare Organizations (Chicago, Illinois) is another major source of standards affecting hospitals. The JCAHO’s Accreditation Manual for Hospitals [JCAHO, 1993] covers the entire spectrum of hospital activities. Pursuit of JCAHO accreditation is voluntary but, in practice, essentially all hospitals seek accreditation to ensure eligibility for reimbursement under certain governmental programs. At present, JCAHO standards include little reference to information systems. However, this is expected to change and, therefore, familiarity with the latest edition of the Accreditation Manual for Hospitals is advisable. Another standard unique to the healthcare system is Health Level 7 (HL7) which is a data communications protocol intended to facilitate the interfacing of various components in a hospital information system [Walker, 1989]. These components range from accounting systems (financial data) to clinical laboratory information systems (laboratory test results) to medical records systems (documentation of patient care services) to patient data management systems (physiological data). In the recent past, each such component was independent and generally incompatible with other components. However, to achieve high quality in patient care at the lowest cost, both administrators and clinicians need integrated, comprehensive access to a wide variety of information. HL7 is an attempt to specify the types of data (and their formats) to be shared within a hospital information system. For example, if all components of the system use a common format for a patient’s name, then it is possible for a single database query to gather all data regarding that patient. This also allows automation of certain activities such as billing (through the accounting system) for laboratory tests ordered by clinicians (through the clinical laboratory system). Unfortunately, HL7 has not achieved its promise but it does represent a significant step away from the chaotic past [Bond et al., 1990]