Informatics & Nephrology

Introduction

The volume and complexity of medical knowledge and data today have far outstripped any physician’s ability to function optimally without the support of information management tools.

The medical knowledge continues to expand rapidly and the demands for more efficient coordination of patient data become paramount, together with requirement of practicing evidence based medicine, all these increase the influence of the medical informatics in our daily practice as clinicians, and the computers are progressively becoming an integral part of the practice of medicine.

Definitions

The terms 'medical informatics' and 'health informatics' have been variously defined, colored and shaded by the definer's background, viewpoint and preoccupation.

Medical Informatics can be defined as the branch of science concerned with the use of computers and communication technology to acquire, store, analyze, communicate, and display medical information and knowledge to facilitate understanding and improve the accuracy, timeliness, and reliability of decision-making.

So, medical informatics is the application of computers, communications and information technology and systems to all fields of medicine - medical care, medical education and medical research.

Fields of Medical Informatics

Medical informatics is the tool that put together rational structures for the way clinical evidence is pooled, communicated, and applied to routine care. It allows us to develop organisational processes and structures that minimise the resources we use, and maximise the benefits delivered.

The scope of informatics is thus enormous:

- Information (knowledge & data) management and decision making

- Communication tasks of medical practice

- Basic science and clinical research

- Medical education

- Planning and policy issues

Knowledge

Let us take an example acquiring the knowledge in the traditional way, and then comparing that with the computerized one to see how the medical informatics could change our professional life.

The main traditional sources of knowledge are the print-based textbooks and journals, either personal or through health science library. You can also acquire knowledge from your colleagues by a formal consultation, or when you ask them informal questions, or when you transfer a patient to an academic health care center, and the patient will come back to you with more clear diagnosis and a good plan for management.

In addition to that there is the CME programs by attending conferences and/or courses.

The computerized sources of knowledge together with the wide spread use of the Internet have transformed our life and the way that we can acquire the knowledge dramatically.

Instead of the printed textbooks and journals the clinical references computer software. Allow you to have an access to and to carry in your handbag a complete medical library.

The best example for that is UpToDate that has more than 40,000 pages of text, and more than 10,000 graphics, written by expert faculty of more than 2,600 clinicians. Also, it contains more than 100,000 Medline abstracts, and an extensive drug database. So when you read a subject you can access the abstracts of its references by just a click of mouse, and if you wont to have more information about a drug that is used to treat that disease it is also just a matter to click on its name and you will have immediately a full prescribing information. Not only that, also you can be sure that you are always current as it is updated every 4 months with the latest medical information from more than 270 journals each month. While the more traditional format, the printed textbook, is almost always outdate as it takes at least tow years to have the textbook prepared and printed… Other examples are ABIM Nephrology , and EMBASE Nephrology for CME.

Many of the paper based clinical textbooks are available in electronic (CD-ROM) format like The Kidney “Brenner and Rector”, Oxfords Textbook of Clinical Nephrology, and many others. Some of the electronic textbooks are accessible also online. Harrison's Online Principle of Internal Medicine offers fee-based access to the latest edition of this esteemed work enhanced with full text search capabilities, multimedia content, updated drugs and therapies, overviews of clinical trials, links to Medline entries and web sites. Physician's Desk Reference, which offers complete entries of brand and generic drugs and includes indications, dosing, adverse affects, and contraindications. Emedicine offers a carefully edited and constantly updated online multimedia emergency medicine textbook The Family Practice Handbook, a National Library of Medicine sponsored project from the University of Iowa's Virtual Hospital, provides a searchable guide for primary care practice. Outlines in Clinical Medicine at Avicenna provides a review of internal medicine in the form of hyperlinked text pages categorized by disease topic. MDConsult offers fee-based searches of full text clinical medicine publications, peer reviewed medical journals and textbooks.

The other source of computerized knowledge, which will give you an access to a huge amount of information, is the Internet. The Internet has provided a multimedia tool for access to medical information that can be reached at the user's convenience via a modem or direct connection.

In fact, many of the clinically useful information can be found on the Web, however many of Web information is unsuitable for direct clinical applications as many of these web sites are created by individuals or for a commercial purpose. One should chose the known high quality web sites, as government agencies (like CDC’s, FDA, ..), academic health care centers, professional specialty organizations, and peer-reviewed journals.

Although the Internet can be helpful for answering clinical questions, and providing the latest relevant information, it could be time consuming. You might need to retrieve huge number of sites, then, retrieve a large set of relevant publications. Some has said, “It is like drinking water from a fire hose”.

Examples of known high quality web sites:

State-of- the-art free Internet Medline has been presented by the National Library of Medicine's using the NCBI's PubMed interface. Internet Grateful Med from the National Library of Medicine and Infotrieve provide alternative Medline interfaces. You can access other bibliographic search software, such as Ovid, Aries Knowledge Finder, SilverPlatter, PaperChase, …

Colleagues:

Your institute might lake the expertise in certain sub-specialties you don’t need to referrals you patient to an academic health care centers or abroad specialized center. You can get the expertise of these top centers while your patient stays in your hospital through the telemedicine. Currently, there are three telemedicine models:

- Interactive video patient consultation

- Teleradiology, telepathology and echocardiography

- “Store and Forward” multimedia clinical consultation.

Other application of the same technology is the TeleHome, in which you can treat your patient in his home and while you are staying in your hospital. Examples, you can manage certain chronic diseases:

– Diabetes (monitoring insulin dosage)

– CHF (managing diuretic use)

– COPD (managing oxygen therapy)

Or follow up post hospitalization:

– High risk premature babies

– Cardiac surgery

Or even you can avoid hospitalization in cases like high risk OB patients

Internet Group of discussion

This has replaced the traditional informal questions that you can ask your colleagues in the same hospital. Internet group of discussion allow your question to reach thousands of colleagues all over the world; some of them will be very difficult to reach them in the traditional way. You will never feel that you are alone even if you are living in a small village in the middle of a desert. Two types of Internet group of discussions e-mail based and a web based. Some examples of e-mail based discussion groups (listservs):

- NEPHROL: Discussing general nephrology, including renal pathology and transplantation.

- NEPHJNL: Nephrology/transplantation journal club.

- NEPJHIST: history of renal medicine, ISN Video Legacy Project interview transcripts.

- NEPHCNPT: discussions of individual clinical nephrology cases.

- NEPHNPPT: discussions of individual renal biopsy cases.

Continuing Medical Education:

This is achieved traditionally by attending physically a Conferences or a course. This is usually costly with all the traveling expenses. With the Internet facilities we can have cyberConferences or online courses in which you will attend the conferences or the course while you are still setting in you office or home.

Commercial vendors have found a niche in offering fee based CME case based modules that are particularly attractive to rural clinicians. NIH Consensus Statement CME Review provides detailed statements regarding current controversies from government sponsored panels of experts. No fees apply. Slack Corporation RealPlayer CME Modules present synchronized slides and commentary. At Medscape, participants review selections from hundreds of available clinical articles and acquire CME units at very low costs.. Medconnect Interactive Education Cases offers monthly essays, sights, sounds and interactive CME quizzes with immediate feedback. cmeWEB Medical Education for Physicians offers emergency medicine and primary care tests for physicians with on-line registration, credit card payment, and online certificate of participation. Continuing Medical Education Modules at Florida offers a series of continuing medical education learning modules addressing clinical medicine topics. The University of Washington offers well constructed radiology digital teaching files available for CME credit hours.

Many of the most interesting lectures given in the top international conferences could be available on-line. The best source of such lectures is the electronic medical journal “HDCN” (www.hdcn.com).

Multimedia Education Modules

The Virtual Hospital is an extensive medical multimedia database that takes full advantage of the Internet medium and incorporates functions such as free text searching, video and audio clips, and high-resolution images. It provides invaluable patient care support and distance learning. The Virtual Medical Center has pointers to thousands of teaching files and cases and highlights continuing medical education courses. A novel use of interactivity and multimedia is demonstrated by an Advanced Cardiac Life Support Module.

Clinical Decision-Support Systems (CDSS)

Clinical Decision-Support Systems are computer application that enhances a human’s ability to make decisions. Given a set of patient findings, the software will:

- Explain differential diagnoses

- Show relevant laboratory tests

- Suggest possible workup protocols

- Provide links to relevant biomedical literature

These applications still under construction. Examples: Dxplain, ILIAD, Meditel

Electronic medical record systems (EMRSs)

They are very efficient for storing and retrieving patient data, Clinician's orders, clinicaltextual reports (e.g., history and P.E.,progress notes, nursing notes, X-Rreports,..), laboratory results, pharmacy information, billing information, and outcome data.

More interesting is the sharing of clinical patient record and the integration of knowledge sources into the workflow of healthcare workers, which will define the new frontier for "Internet Medicine." Hospital-to-hospital health data transfers are taking place over the Internet using consensus standards. Many web-based demonstration projects are available on the Internet that demonstrates the intense activities of vendors and research. A list of web-based Electronic Medical Record System Demonstrations is available at Columbia. A journal, Health Data Management, presents full text of the latest developments in this field. It has become a common view that the web browser will be the electronic medical record interface for the 1990s.

Medical Education Software

Dozens of free medical software products can be downloaded from WWW sites. Most are labor-of-love or precommercial versions made available by their creator/ developers or organizations. If you are interested in commercial medical education software products Yahoo's Medical Education Software, lists 37 online companies,

The University of Aberdeen and Leeds' BioNet offers a Software Compendium covering basic and clinical sciences, information technology, and statistics, many of which use (and hence require) Toolbook. At time of writing NYU's Resources for Health Education -- Software has two offerings: NUDIST Qualitative Analysis Software, and EMPOWER, for teaching and implementing community health projects. The Centers for Disease Control site has reputedly excellent epidemiology and statistical software that can be freely downloaded. Included here is also at least one interactive learning program. Epidemiology, statistical, and new problem-based learning software is available for downloading from MEO's Resource Section.

The University of California at Irvine's MED-ED Software Archives has a large assortment of downloadable programs dating back to 1992. Some software is available from Stanford University's Courseware Distribution Site. Anesthesia freeware is available from GASNET's Software Directory. For those who love surprises, many unidentified medical programs are listed in the _Brazilian Medical Software Archives File Transfer Protocol (FTP) site; everyone else should first look at the program descriptions. Fans of the Newton handheld palmtop should find Newton Medical Web Site useful.