MPH 210

Public Health Informatics

Lecture 2: Technology 101
 Part 1:
Technology Basics
Information technology basics
Personal computers and servers
Computer basics - operating system, application,
networking
Internet basics - tcp/ip, messages, data exchange
Databases 101 - storing information
Computer Types
Desktop (PC), laptops

PDA

Server
 Computer anatomy

CPU – central
processing
unit

“Motherboard”

PC internal view

Integrated
Circuit
6 Computers software…
BIOS – Basic Input/Output System
Low-level program that interfaces the CPU with its ‘eyes and ears’
(keyboard, mouse, drives)
Manages control of the hardware that is attached to the
motherboard/CPU (disk drive, keyboard, speaker, video card,
etc..)
“Loaded” from an onboard chip that comes with the computer
(cannot be erased)
Operating System
Medium-level program that provides more sophisticated control
over storage devices (drives), memory allocation, video, audio by
higher level programs
Typically is the ‘brains’ of the computer – must be “read/loaded”
from a fixed disk each time the computer is turned on (can be
erased)
 System.out.println(“Hello World”);

IDENTIFICATION DIVISION.

Applications
PROGRAM-ID. HELLO-WORLD.
PROCEDURE DIVISION.
PARA-1.
DISPLAY "Hello, world.".
STOP RUN.

Application
A “high-level program” developed for specific functional purposes
(word processors, spreadsheets, web browsers, web servers, email
servers, etc..)
Interacts with the operating system to read/write data to devices
such as the disk drives, USB memory sticks, video, printer, etc..
It is often “operating system specific” because it needs to interact
with all these devices, which are controlled by the operating system
you can’t run a Mac program unmodified on a Windows machine
Applications are ‘written’ in a programming language, which is an
“english-like” syntax used to command the operating system to do
certain things
Programs...
compiler

compiled
program
program

run program

programmer “writes”
a program
9 Internet basics
“The Internet” – a collection of computers connected over
physical connections and using TCP/IP to communicate
TCP - Transmission Control Protocol
TCP enables two hosts to establish a connection and
exchange streams of data. TCP guarantees delivery of data
and also guarantees that packets will be delivered in the
same order in which they were sent.
IP - Internet Protocol. IP specifies the format of packets, also
called datagrams, and the addressing scheme. IP is combined
with TCP, which establishes a virtual connection between a
destination and a source.
 server
TCP/IP =
negotiates
information server
transfer
‘client’ 1000111011001

‘client’

server
HELO
+OK
mail
server
RETR 1
+OK

“This is a dummy email.”

POP3

DEL 1 +OK
Database systems
Flat-file text databases (with storage/retrieval software)
Associative flat-file databases such as Berkeley DB
Relational databases
Object databases
Hierarchical databases such as MUMPS, a commonly used system
in healthcare even today
Database management
systems
A database management system (DBMS) is a collection of
software which can be used to create, maintain and work with
databases.
Most common DBMS today – relational database systems (Oracle,
Sybase, MS SQL, etc..)
SQL – Structured Query Language
English-like language used to manipulate relational DBMS
systems
Example…
Hierarchical databases
Hierarchical databases organize data in tree-like structures
Parent-children structure
Examples
MUMPS

Berkeley DB
Relational databases
Systems that use a relational model for organizing information - rows/columns

Examples

Oracle

Sybase

DB2

MySQL

PostgreSQL

Microsoft Access
 Part 2:
Healthcare Information
Technology
Healthcare IT (HIT)
Information technology used to improve
health quality and improve efficiency
prevent medical errors
optimize diagnosis and therapy (DSS)
decrease paper processes
disease management
Uses of IT in healthcare
Electronic medical records
Imaging (digital radiology, digital pathology)
Electronic financial transactions
Administrative systems
Clinical Research - clinical informatics
Basic Research - bioinformatics
Public Health - public health informatics
What is an EMR?
Electronic Medical Record System vs. Computer
Based Patient Record System
Computer-based Patient Record System
(CPRS). "The set of components that form the
mechanisms by which patient records are
created, used, stored and retrieved...It includes
people, data, rules and procedures, processing
and storage devices, and communications and
support facilities”
“Computer-based Patient Records: An Essential Technology for Health Care “
A focus on the EMR
“a medical record in digital format”

Are all “EMRs” the same? Everyone talks like they are the same, but are they?

What is an EMR? Outpatient (ambulatory records) vs. Inpatient, has the hospital implemented
all components? What to implement first?

Functional viewpoint - “what does your EMR do for you?”

Results reporting - text, digital images

Medical Management

Clinical documentation

Communication

Order Entry - CPOE

Clinical Decision Support Systems (CDSS)

Clinical Information Systems
- how modern are they?

Blum, West J Med. 1986 December; 145(6): 791–797.

Adoption statistics

DesRoches et al (NEJM,
2008)
~2500 physicians surveyed
(62% res rate)

4 % had a fully functional

system
13% had a ‘basic system’
Simon et al (JAMIA, 2007)
1,345 surveyed ( corresponds to a 71% response rate)
random sample of Massachusetts practices
45% of physicians using EHRs
23% of practices had an EHR
Practices with >7 had 52% adoption, solo practitioners
had 14% adoption
Simon et al
(J. of Evaluation in Clinical Practice, 2006)
most common functionality
notes
lab results
medication lists
Barriers to adoption

Simon et al (J. of Evaluation in Clinical Practice,

2006)
Costs
Roughly $30,000 - $50,000 per physician as a
start up, then 20% of that annually to support
it
Predicted ‘break even point’ has been
calculated as anywhere between 3-12 years.
2002 study - 280 bed hospital, 16 outpatient
clinics, ~400 physicians = $19 million
ADEs
Adverse Druge Events (ADEs) - estimated
770,000 people annually are injured or die
in hospitals from ADEs
28% of ADEs are due to medication errors
(judged to be preventable)
Of preventable ADEs, 56% happened during
drug ordering
Kaushal, Shojania, and Bates. Arch Intern Med. 2003;
163:1409-1416
CPOE
Computerized Physician Order Entry (CPOE)
Overhage et al (1997) - 25% improvement in ordering medications
by faculty and residents
Bates (1998) - 6,771 adult inpatients. 55% decrease in non-
intercepted serious medication errors
Bates (1999) - 1,817 adult inpatients. 81% decrease in medication
errors
Chertow (2001) - 7,490 adult patients with renal disease. 13%
decrease in wrong dosing, 25% decrease in wrong frequency

Kaushal, Shojania, and Bates. Arch Intern Med. 2003;

163:1409-1416
EMRs and CPOE
Petersen et al (2001)- 25.7% of surveyed hospitals
that had electronic prescribing actually lacked
information system linkages to pharmacy systems
-- required re-typing of orders...
Ash et al (1998) - survey of 668 hospitals showed
only 15% had ‘at least partially implemented CPOE’
Petersen (2001) - survey of 1,091 acute care
hospitals. Only 4.3% had an electronic medication
order-entry system in place
Decision Support
Clinical Decision Support Systems (CDSS)
the functionality in systems that provides decision
‘augmentation’
Examples:
system alerts
system reminders
system suggestions
Benefits
Mullett et al - 59% reduction in pharmacists
interventions for erroneous drug doses
Hillestad et al (Health Affairs, 2005)
extrapolated ADE cost according to hospital size/beds,
also calculated productivity increase based on
retail/wholesale experience with IT
avoided ADE costs = $3.5 billion (2million avoided
events @ ~$1,000-$2,000/ea)
90% adoption = $77 billion annual productivity
savings
 90% adoption of health IT could result in
$35 billion -140 billion annual productivity savings

per year
billion
If effect of HIT is 1.5 %

35
productivity increase
(effect of IT on retail
industry)

107 billion
per year
If effect of HIT is 4% productivity improvement
(1/2 that of what telecomm experienced with
IT use)
Failures in Healthcare IT
Cedars Sinai Medical Center (Los Angeles) -- administration forced to scrap a
CPOE ($34 million) due to physician dissatisfaction with the system
Upwards of 30% of EHR implementation attempts have failed over the past
few years [National Health Information Network Co-ordinator, David Brailer]
In general, 20-30% of Information technology projects are canceled before
the produce anything [ CHAOS Study, 2006]
Dr. Brailer's own Santa Barbara County Care Data Exchange, and the basis
for the Regional Health Information Organization (RHIO), failed for a variety
of reasons including poor project management, technical challenges, and a
failure to evolve to a sustainable business model
2009 - ARRA and HITECH Act -
$180 billion for healthcare IT
Meaningful Use
Stage 1 - primarily focuses on collecting electronic health data
in coded formats
Stage 2 - focuses on implementation of structured data
exchange and continuous quality improvement
Stage 3 - focuses on advanced decision support and population
health
Incentive Payments
Eligible providers (EPs) - up to $63,750 over 6 years under
Medicaid
Hospitals - $2 million per hospital