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Health informatics (also called health care informatics, healthcare informatics, medical informatics, nursing informatics, clinical informatics, or biomedical informatics) is informatics in health care. It is a multidisciplinary field that uses health information technology (HIT) to improve health care via any combination of higher quality, higher efficiency (spurring lower cost and thus greater availability), and new opportunities. The disciplines involved include information science, computer science, social science, behavioral science, management science, and others. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include amongst others computers, clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health, occupational therapy, physical therapy and (bio)medical research, and alternative medicine.
- The international standards on the subject are covered by ICS 35.240.80 in which ISO 27799:2008 is one of the core components.
- Molecular bioinformatics and clinical informatics have converged into the field of translational bioinformatics.
- 1 Sub Specialities
- 2 Healthcare Informatics
- 3 Human Bioinformatics
- 4 Computational Health Informatics
- 5 Informatics for Education & Research in Health & Medicine
- 6 Medical informatics in the United States
- 7 Medical informatics in the UK
- 8 Current state of health informatics and policy initiatives
- 8.1 Argentina
- 8.2 Brazil
- 8.3 Canada
- 8.4 United States
- 8.5 Europe
- 8.6 Asia and Oceania
- 8.7 Post Soviet Countries
- 9 Health Informatics Law
- 10 History
- 11 Leading health informatics and medical informatics journals
- 12 See also
- 13 References
- 14 External links
- Healthcare Informatics
- Consumer Health Informatics
- Clinical Bioinformatics
- Informatics for Education & Research in Health & Medicine
Clinical informaticians transform health care by analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve [patient] care, and strengthen the clinician-patient relationship. Clinical informaticians use their knowledge of patient care combined with their understanding of informatics concepts, methods, and health informatics tools to:
- assess information and knowledge needs of health care professionals and patients,
- characterize, evaluate, and refine clinical processes,
- develop, implement, and refine clinical decision support systems, and
- lead or participate in the procurement, customization, development, implementation, management, evaluation, and continuous improvement of clinical information systems.
Clinicians collaborate with other health care and information technology professionals to develop health informatics tools which promote patient care that is safe, efficient, effective, timely, patient-centered, and equitable.
In October 2011 American Board of Medical Specialties (ABMS), the organization overseeing the certification of physician specialists (MD Physicians only) in the United States, announced the creation of physician (MD physicians only) certification in Clinical Informatics. The first examination for board certification in the subspecialty of Clinical Informatics was offered in October 2013 by American Board of Preventive Medicine with 432 passing to become the 2014 inaugural class of Diplomates (ABPM) in Clinical Informatics.
Fellowship programs exist for physicians who wish to become board-certified in Clinical Informatics. Physicians must have graduated from a medical school in the United States or Canada, or a school located elsewhere that is approved by the ABPM. In addition, the must complete a primary residency program such as Internal Medicine (or any of the 24 subspecialties recognized by the ABMS) and be eligible to become licensed to practice medicine in the state where their fellowship program is located. The fellowship program is 24 months in length, with fellows dividing their time between Informatics rotations, didactics, research, and clinical work in their primary specialty.
Integrated data repository
Development of the field of clinical informatics lead to creation of large data sets with electronic health record data integrated with other data (such as genomic data). Large data warehouses are often described as clinical data warehouses (also known as clinical data repositories). In research, deidentified CDWs can be used by researchers with less complex ethical oversight. CDWs with data of deceased patients were also suggested as a research resource that does not require IRB approval.
With the completion of the human genome and the recent advent of high throughput sequencing and genome-wide association studies of single nucleotide polymorphisms, the fields of molecular bioinformatics, biostatistics, statistical genetics and clinical informatics are converging into the emerging field of translational bioinformatics.
The relationship between bioinformatics and health informatics, while conceptually related under the umbrella of biomedical informatics, has not always been very clear. The TBI community is specifically motivated with the development of approaches to identify linkages between fundamental biological and clinical information.
Along with complementary areas of emphasis, such as those focused on developing systems and approaches within clinical research contexts, insights from TBI may enable a new paradigm for the study and treatment of disease.
Computational Health Informatics
Computational Health Informatics
Computational health informatics is a branch of Computer Science that deals specifically with computational techniques that are relevant in healthcare. Computational health informatics is also a branch of Health Informatics, but is orthogonal to much of the work going on in health informatics because computer scientist's interest is mainly in understanding fundamental properties of computation. Health informatics, on the other hand, is primarily concerned with understanding fundamental properties of medicine that allow for the intervention of computers. The health domain provides an extremely wide variety of problems that can be tackled using computational techniques, and computer scientists are attempting to make a difference in medicine by studying the underlying principles of computer science that will allow for meaningful (to medicine) algorithms and systems to be developed. Thus, computer scientists working in computational health informatics and health scientists working in medical health informatics combine to develop the next generation of healthcare technologies.
Using computers to analyze health data has been around since the 1950s, but it wasn't until the 1990s that the first sturdy models appeared. The development of the internet has helped develop computational health informatics over the past decade. Computer models are used to examine various topics such as how exercise affects obesity, healthcare costs, and many more.
Informatics for Education & Research in Health & Medicine
Clinical Research Informatics
Clinical Research Informatics (or, CRI) takes the core foundations, principles, and technologies related to Health Informatics, and applies these to clinical research contexts. As such, CRI is a sub-discipline of Health Informatics, and interest and activities in CRI have increased greatly in recent years given the overwhelming problems associated with the explosive growth of clinical research data and information. There are a number of activities within clinical research that CRI supports, including:
- more efficient and effective data collection and acquisition
- improved recruitment into clinical trials
- optimal protocol design and efficient management
- patient recruitment and management
- adverse event reporting
- regulatory compliance
- data storage, transfer, processing and analysis
- repositories of data from completed clinical trials (for secondary analyses)
Medical informatics in the United States
Even though the idea of using computers in medicine emerged as technology advanced in the early 20th century, it was not until the 1950s that informatics began to have an effect in the United States.
The earliest use of electronic digital computers for medicine was for dental projects in the 1950s at the United States National Bureau of Standards by Robert Ledley. During the mid-1950s, the United States Air Force (USAF) carried out several medical projects on its computers while also encouraging civilian agencies such as the National Academy of Sciences - National Research Council (NAS-NRC) and the National Institutes of Health (NIH) to sponsor such work. In 1959, Ledley and Lee B. Lusted published "Reasoning Foundations of Medical Diagnosis," a widely read article in Science, which introduced computing (especially operations research) techniques to medical workers. Ledley and Lusted’s article has remained influential for decades, especially within the field of medical decision making.
Guided by Ledley's late 1950s survey of computer use in biology and medicine (carried out for the NAS-NRC), and by his and Lusted's articles, the NIH undertook the first major effort to introduce computers to biology and medicine. This effort, carried out initially by the NIH's Advisory Committee on Computers in Research (ACCR), chaired by Lusted, spent over $40 million between 1960 and 1964 in order to establish dozens of large and small biomedical research centers in the US.
One early (1960, non-ACCR) use of computers was to help quantify normal human movement, as a precursor to scientifically measuring deviations from normal, and design of prostheses. The use of computers (IBM 650, 1620, and 7040) allowed analysis of a large sample size, and of more measurements and subgroups than had been previously practical with mechanical calculators, thus allowing an objective understanding of how human locomotion varies by age and body characteristics. A study co-author was Dean of the Marquette University College of Engineering; this work led to discrete Biomedical Engineering departments there and elsewhere.
The next steps, in the mid-1960s, were the development (sponsored largely by the NIH) of expert systems such as MYCIN and Internist-I. In 1965, the National Library of Medicine started to use MEDLINE and MEDLARS. Around this time, Neil Pappalardo, Curtis Marble, and Robert Greenes developed MUMPS (Massachusetts General Hospital Utility Multi-Programming System) in Octo Barnett's Laboratory of Computer Science  at Massachusetts General Hospital in Boston, another center of biomedical computing that received significant support from the NIH. In the 1970s and 1980s it was the most commonly used programming language for clinical applications. The MUMPS operating system was used to support MUMPS language specifications. As of 2004[update], a descendent of this system is being used in the United States Veterans Affairs hospital system. The VA has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA's over 1,000 health care facilities.
During the 1960s, Morris Collen, a physician working for Kaiser Permanente's Division of Research, developed computerized systems to automate many aspects of multiphasic health checkups. These system became the basis the larger medical databases Kaiser Permanente developed during the 1970s and 1980s. The American College of Medical Informatics (ACMI) has since 1993 annually bestowed the Morris F. Collen, MD Medal for Outstanding Contributions to the Field of Medical Informatics.
In the 1970s a growing number of commercial vendors began to market practice management and electronic medical records systems. Although many products exist, only a small number of health practitioners use fully featured electronic health care records systems.
Homer R. Warner, one of the fathers of medical informatics, founded the Department of Medical Informatics at the University of Utah in 1968. The American Medical Informatics Association (AMIA) has an award named after him on application of informatics to medicine.
Like other IT training specialties, there are Informatics certifications available to help informatics professionals stand out and be recognized. The American Nurses Credentialing Center (ANCC) offers a board certification in Nursing Informatics. For Radiology Informatics, the CIIP (Certified Imaging Informatics Professional) certification was created by ABII (The American Board of Imaging Informatics) which was founded by SIIM (the Society for Imaging Informatics in Medicine) and ARRT (the American Registry of Radiologic Technologists) in 2005. The CIIP certification requires documented experience working in Imaging Informatics, formal testing and is a limited time credential requiring renewal every five years. The exam tests for a combination of IT technical knowledge, clinical understanding, and project management experience thought to represent the typical workload of a PACS administrator or other radiology IT clinical support role. Certifications from PARCA (PACS Administrators Registry and Certifications Association) are also recognized. The five PARCA certifications are tiered from entry level to architect level.
Medical informatics in the UK
The broad history of health informatics has been captured in the book UK Health Computing : Recollections and reflections, Hayes G, Barnett D (Eds.), BCS (May 2008) by those active in the field, predominantly members of BCS Health and its constituent groups. The book describes the path taken as ‘early development of health informatics was unorganized and idiosyncratic’. In the early -1950s it was prompted by those involved in NHS finance and only in the early 1960s did solutions including those in pathology (1960), radiotherapy (1962), immunization (1963), and primary care (1968) emerge. Many of these solutions, even in the early 1970s were developed in-house by pioneers in the field to meet their own requirements. In part this was due to some areas of health services (for example the immunization and vaccination of children) still being provided by Local Authorities. Interesting, this is a situation which the coalition government propose broadly to return to in the 2010 strategy Equity and Excellence: Liberating the NHS (July 2010); stating:
"We will put patients at the heart of the NHS, through an information revolution and greater choice and control’ with shared decision-making becoming the norm: ‘no decision about me without me’ and patients having access to the information they want, to make choices about their care. They will have increased control over their own care records."
These types of statements present a significant opportunity for health informaticians to come out of the back-office and take up a front-line role supporting clinical practice, and the business of care delivery. The UK health informatics community has long played a key role in international activity, joining TC4 of the International Federation of Information Processing (1969) which became IMIA (1979). Under the aegis of BCS Health, Cambridge was the host for the first EFMI Medical Informatics Europe (1974) conference and London was the location for IMIA’s tenth global congress (MEDINFO2001).
Current state of health informatics and policy initiatives
This article reads like a review rather than an encyclopedic description of the subject. (August 2009)
Since 1997, the Buenos Aires Biomedical Informatics Group, a nonprofit group, represents the interests of a broad range of clinical and non-clinical professionals working within the Health Informatics sphere. Its purposes are:
- Promote the implementation of the computer tool in the healthcare activity, scientific research, health administration and in all areas related to health sciences and biomedical research.
- Support, promote and disseminate content related activities with the management of health information and tools they used to do under the name of Biomedical informatics.
- Promote cooperation and exchange of actions generated in the field of biomedical informatics, both in the public and private, national and international level.
- Interact with all scientists, recognized academic stimulating the creation of new instances that have the same goal and be inspired by the same purpose.
- To promote, organize, sponsor and participate in events and activities for training in computer and information and disseminating developments in this area that might be useful for team members and health related activities.
The Argentinian health system is heterogeneous in its function, and because of that the informatics developments show a heterogeneous stage. Many private Health Care center have developed systems, such as the Hospital Aleman of Buenos Aires, or the Hospital Italiano de Buenos Aires that also has a residence program for health informatics.
The first applications of computers to medicine and healthcare in Brazil started around 1968, with the installation of the first mainframes in public university hospitals, and the use of programmable calculators in scientific research applications. Minicomputers, such as the IBM 1130 were installed in several universities, and the first applications were developed for them, such as the hospital census in the School of Medicine of Ribeirão Preto and patient master files, in the Hospital das Clínicas da Universidade de São Paulo, respectively at the cities of Ribeirão Preto and São Paulo campuses of the University of São Paulo. In the 1970s, several Digital Corporation and Hewlett Packard minicomputers were acquired for public and Armed Forces hospitals, and more intensively used for intensive-care unit, cardiology diagnostics, patient monitoring and other applications. In the early 1980s, with the arrival of cheaper microcomputers, a great upsurge of computer applications in health ensued, and in 1986 the Brazilian Society of Health Informatics was founded, the first Brazilian Congress of Health Informatics was held, and the first Brazilian Journal of Health Informatics was published. In Brazil, two universities are pioneers in teaching and research in Medical Informatics, both the University of Sao Paulo and the Federal University of Sao Paulo offer undergraduate programs highly qualified in the area as well as extensive graduate programs (MSc and PhD). In 2015 the Universidade Federal de Ciências da Saúde de Porto Alegre, Rio Grande do Sul, also started to offer undergraduate program.
Health Informatics projects in Canada are implemented provincially, with different provinces creating different systems. A national, federally funded, not-for-profit organization called Canada Health Infoway was created in 2001 to foster the development and adoption of electronic health records across Canada. As of December 31, 2008 there were 276 EHR projects under way in Canadian hospitals, other health-care facilities, pharmacies and laboratories, with an investment value of $1.5-billion from Canada Health Infoway.
Provincial and territorial programmes include the following:
- eHealth Ontario was created as an Ontario provincial government agency in September 2008. It has been plagued by delays and its CEO was fired over a multimillion-dollar contracts scandal in 2009.
- Alberta Netcare was created in 2003 by the Government of Alberta. Today the netCARE portal is used daily by thousands of clinicians. It provides access to demographic data, prescribed/dispensed drugs, known allergies/intolerances, immunizations, laboratory test results, diagnostic imaging reports, the diabetes registry and other medical reports. netCARE interface capabilities are being included in electronic medical record products which are being funded by the provincial government.
In 2004, President George W. Bush signed Executive Order 13335, creating the Office of the National Coordinator for Health Information Technology (ONCHIT) as a division of the U.S. Department of Health and Human Services (HHS). The mission of this office is widespread adoption of interoperable electronic health records (EHRs) in the US within 10 years. See quality improvement organizations for more information on federal initiatives in this area.
In 2014 The Department of Education approved an advanced Health Informatics Undergraduate program that was submitted by The University of South Alabama. The program is designed to provide specific Health Informatics education, and is the only program in the country with a Health Informatics Lab. The program is housed in The School of Computing in Shelby Hall, a recently completed $50 million state of the art teaching facility. The University of South Alabama awarded David L. Loeser on May 10, 2014 with the first Health Informatics degree. The program currently is scheduled to have 100+ students awarded by 2016.
The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards for electronic health records (EHR) and supporting networks, and certify vendors who meet them. In July 2006, CCHIT released its first list of 22 certified ambulatory EHR products, in two different announcements.
The European Union's Member States are committed to sharing their best practices and experiences to create a European eHealth Area, thereby improving access to and quality health care at the same time as stimulating growth in a promising new industrial sector. The European eHealth Action Plan plays a fundamental role in the European Union's strategy. Work on this initiative involves a collaborative approach among several parts of the Commission services. The European Institute for Health Records is involved in the promotion of high quality electronic health record systems in the European Union.
There are different models of health informatics delivery in each of the home countries (England, Scotland, Northern Ireland and Wales) but some bodies like UKCHIP  (see below ) operate for those 'in and for' all the home countries and beyond.
NHS informatics in England was contracted out to several vendors for national health informatics solutions under the National Programme for Information Technology (NPfIT) label in the early to mid-2000's, under the auspices of NHS Connecting for Health (part of the Health and Social Care Information Centre as of 1 April 2013). NPfIT originally divided the country into five regions, with strategic 'systems integration' contracts awarded to one of several Local Service Providers (LSP). The various specific technical solutions were required to connect securely with the NHS 'Spine', a system designed to broker data between different systems and care settings. NPfIT fell significantly behind schedule and its scope and design were being revised in real time, exacerbated by media and political lambasting of the Programme's spend (past and projected) against proposed budget. In 2010 a consultation was launched as part of the new Conservative/Liberal Democrat Coalition Government's White Paper 'Liberating the NHS'. This initiative provided little in the way of innovative thinking, primarily re-stating existing strategies within the proposed new context of the Coalition's vision for the NHS. The degree of computerisation in NHS secondary care was quite high before NPfIT, and the programme stagnated further development of the install base - the original NPfIT regional approach provided neither a single, nationwide solution nor local health community agility or autonomy to purchase systems, but instead tried to deal with a hinterland in the middle. Almost all general practices in England and Wales are computerised under the 'GP Systems of Choice' (GPSoC) programme, and patients have relatively extensive computerised primary care clinical records. System choice is the responsibility of individual general practices and while there is no single, standardised GP system, GPSoC sets relatively rigid minimum standards of performance and functionality for vendors to adhere to. Interoperation between primary and secondary care systems is rather primitive. It is hoped that a focus on interworking (for interfacing and integration) standards will stimulate synergy between primary and secondary care in sharing necessary information to support the care of individuals. Notable successes to date are in the electronic requesting and viewing of test results, and in some areas GPs have access to digital X-ray images from secondary care systems. Scotland has an approach to central connection under way which is more advanced than the English one in some ways. Scotland has the GPASS system whose source code is owned by the State, and controlled and developed by NHS Scotland. GPASS was accepted in 1984. It has been provided free to all GPs in Scotland but has developed poorly. Discussion of open sourcing it as a remedy is occurring.
Wales has a dedicated Health Informatics function that supports NHS Wales in leading on the new integrated digital information services and promoting Health Informatics as a career.
Emerging Directions (European R&D)
The European Commission's preference, as exemplified in the 5th Framework as well as currently pursued pilot projects, is for Free/Libre and Open Source Software (FLOSS) for healthcare. Another stream of research currently focuses on aspects of "big data" in health information systems. For background information on data-related aspects in health informatics see, e.g., the book "Biomedical Informatics"  by Andreas Holzinger.
Asia and Oceania
In Asia and Australia-New Zealand, the regional group called the Asia Pacific Association for Medical Informatics (APAMI) was established in 1994 and now consists of more than 15 member regions in the Asia Pacific Region.
The Australasian College of Health Informatics (ACHI) is the professional association for health informatics in the Asia-Pacific region. It represents the interests of a broad range of clinical and non-clinical professionals working within the health informatics sphere through a commitment to quality, standards and ethical practice. ACHI is an academic institutional member of the International Medical Informatics Association (IMIA) and a full member of the Australian Council of Professions. ACHI is a sponsor of the "e-Journal for Health Informatics", an indexed and peer-reviewed professional journal. ACHI has also supported the "Australian Health Informatics Education Council" (AHIEC) since its founding in 2009.
Although there are a number of health informatics organisations in Australia, the Health Informatics Society of Australia (HISA) is regarded as the major umbrella group and is a member of the International Medical Informatics Association (IMIA). Nursing informaticians were the driving force behind the formation of HISA, which is now a company limited by guarantee of the members. The membership comes from across the informatics spectrum that is from students to corporate affiliates. HISA has a number of branches (Queensland, New South Wales, Victoria and Western Australia) as well as special interest groups such as nursing (NIA), pathology, aged and community care, industry and medical imaging (Conrick, 2006).
At last 20 years, China performed a successful transition from its planned economy to a socialist market economy. Along this great and earth-shaking change, China’s healthcare system also experienced a significant reform to follow and adapt to this historical revolution. In 2003, the data (released from Ministry of Health of the People's Republic of China (MoH)), indicated that the national healthcare-involved expenditure was up to RMB 662.33 billion totally, which accounted for about 5.56% of nationwide gross domestic products. Before the 1980s, the entire healthcare costs were covered in central government annual budget. Since that, the construct of healthcare-expended supporters started to change gradually. Most of the expenditure was contributed by health insurance schemes and private spending, which corresponded to 40% and 45% of total expenditure, respectively. Meanwhile, the financially governmental contribution was decreased to 10% only. On the other hand, by 2004, up to 296,492 healthcare facilities were recorded in statistic summary of MoH, and an average of 2.4 clinical beds per 1000 people were mentioned as well.
Health Informatics in China
Along with the development of information technology since the 1990s, healthcare providers realised that the information could generate significant benefits to improve their services by computerised cases and data, for instance of gaining the information for directing patient care and assessing the best patient care for specific clinical conditions. Therefore, substantial resources were collected to build China's own health informatics system. Most of these resources were arranged to construct Hospital Information System (HIS), which was aimed to minimise unnecessary waste and repetition, subsequently to promote the efficiency and quality-control of healthcare. By 2004, China had successfully spread HIS through approximately 35-40% of nationwide hospitals. However, the dispersion of hospital-owned HIS varies critically. In the east part of China, over 80% of hospitals constructed HIS, in northwest of China the equivalent was no more than 20%. Moreover, all of the Centers for Disease Control and Prevention (CDC) above rural level, approximately 80% of healthcare organisations above the rural level and 27% of hospitals over town level have the ability to perform the transmission of reports about real-time epidemic situation through public health information system and to analysis infectious diseases by dynamic statistics.
China has four tiers in its healthcare system. The first tier is street health and workplace clinics and these are cheaper than hospitals in terms of medical billing and act as prevention centers. The second tier is district and enterprise hospitals along with specialist clinics and these provide the second level of care. The third tier is provisional and municipal general hospitals and teaching hospitals which provided the third level of care. In a tier of its own is the national hospitals which are governed by the Ministry of Health. China has been greatly improving its health informatics since it finally opened its doors to the outside world and joined the World Trade Organization (WTO). In 2001, it was reported that China had 324,380 medical institutions and the majority of those were clinics. The reason for that is that clinics are prevention centers and Chinese people like using traditional Chinese medicine as opposed to Western medicine and it usually works for the minor cases. China has also been improving its higher education in regards to health informatics. At the end of 2002, there were 77 medical universities and medical colleges. There were 48 university medical colleges which offered bachelor, master, and doctorate degrees in medicine. There were 21 higher medical specialty institutions that offered diploma degrees so in total, there were 147 higher medical and educational institutions. Since joining the WTO, China has been working hard to improve its education system and bring it up to international standards. SARS played a large role in China quickly improving its healthcare system. Back in 2003, there was an outbreak of SARS and that made China hurry to spread HIS or Hospital Information System and more than 80% of hospitals had HIS. China had been comparing itself to Korea’s healthcare system and figuring out how it can better its own system. There was a study done that surveyed six hospitals in China that had HIS. The results were that doctors didn’t use computers as much so it was concluded that it wasn’t used as much for clinical practice than it was for administrative purposes. The survey asked if the hospitals created any websites and it was concluded that only four of them had created websites and that three had a third-party company create it for them and one was created by the hospital staff. In conclusion, all of them agreed or strongly agreed that providing health information on the Internet should be utilized.
Health Informatics Standards in China
Collected information at different times, by different participants or systems could frequently lead to issues of misunderstanding, dis-comparing or dis-exchanging. To design an issues-minor system, healthcare providers realised that certain standards were the basis for sharing information and interoperability, however a system lacking standards would be a large impediment to interfere the improvement of corresponding information systems. Given that the standardisation for health informatics depends on the authorities, standardisation events must be involved with government and the subsequently relevant funding and supports were critical. In 2003, the Ministry of Health released the Development Lay-out of National Health Informatics (2003–2010) indicating the identification of standardisation for health informatics which is ‘combining adoption of international standards and development of national standards’.
In China, the establishment of standardisation was initially facilitated with the development of vocabulary, classification and coding, which is conducive to reserve and transmit information for premium management at national level. By 2006, 55 international/ domestic standards of vocabulary, classification and coding have served in hospital information system. In 2003, the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and the ICD-10 Clinical Modification (ICD-10-CM) were adopted as standards for diagnostic classification and acute care procedure classification. Simultaneously, the International Classification of Primary Care (ICPC) were translated and tested in China ’s local applied environment. Another coding standard, named Logical Observation Identifiers Names and Codes (LOINC), was applied to serve as general identifiers for clinical observation in hospitals. Personal identifier codes were widely employed in different information systems, involving name, sex, nationality, family relationship, educational level and job occupation. However, these codes within different systems are inconsistent, when sharing between different regions. Considering this large quantity of vocabulary, classification and coding standards between different jurisdictions, the healthcare provider realised that using multiple systems could generate issues of resource wasting and a non-conflicting national level standard was beneficial and necessary. Therefore, in late 2003, the health informatics group in Ministry of Health released three projects to deal with issues of lacking national health information standards, which were the Chinese National Health Information Framework and Standardisation, the Basic Data Set Standards of Hospital Information System and the Basic Data Set Standards of Public Health Information System.
|Objectives of Chinese National Health Information Framework and Standardisation|
|1. Establish national health information framework and identify in what areas standards and guidelines are required|
|2. Identify the classes, relationships and attributes of national health information framework. Produce a conceptual health data model to cover the scope of the health information framework|
|3. Create logical data model for specific domains, depicting the logical data entities, the data attributes, and the relationships between the entities according to the conceptual health data model|
|4. Establish uniform represent standard for data elements according to the data entities and their attributes in conceptual data model and logical data model|
|5. Circulate the completed health information framework and health data model to the partnership members for review and acceptance|
|6. Develop a process to maintain and refine the China model and to align with and influence international health data models|
Comparison between China's EHR Standard and Segments of the ASTM E 1384 Standard
Recently, researchers from local universities evaluated the performance of China’s Electronic Health Record(EHR) Standard compared with the American Society for Testing and Materials Standard Practice for Content and Structure of Electronic Health Records in the United States (ASTM E 1384 Standard).
|China’s EHR Standard||ASTM E 1384 Standard|
|● H.01 Document identifier, H.02 Service object identifier, H.03Demographics, H.04 Contact person, H.05 Address, H.06 Contacts||● Seg1 Demographic/Administrative, Seg14A Administrative/Diagnostic
|● H.07 Medical insurance|
|● H.08 Healthcare institution, H.09 Healthcare practitioner||● Seg4 Provider/Practitioners|
|● H.10 Event summary||● Seg5 Problem List, Seg14A Administrative/Diagnostic Summary|
|● S.01 Chief complaints||● Seg14B Chief Complaint Present Illness/Trauma Care|
|● S.02 Physical exam||● Seg9 Assessments/Exams|
|● S.03 Present illness history||● Seg14B Chief Complaint Present Illness/Trauma Care|
|● S.04 Past medical history||● Seg5 Problem List, Seg6 Immunizations, Seg7 Exposure to Hazardous Substances, Seg8 Family/Prenatal/Cumulative Health/Medical/Dental Nursing History|
|● S.05 Specific Exam, S.06 Lab data||● Seg11 Diagnostic Tests|
|● S.07 Diagnoses||● Seg5 Problem List, Seg14A Administrative/Diagnostic Summary|
|● S.08 Procedures||● Seg14E Procedures|
|● S.09 Medications||● Seg12 Medications|
|● S.10 Care/treatment plans||● Seg2 Legal Agreements, Seg10 Care/Treatment Plans and Orders, Seg13 Scheduled Appointments/Events|
|● S.11 Assessments||● Seg9 Assessments/Exams|
|● S.12 Encounters/episodes notes||● Seg14C Progress Notes/Clinical Course, Seg14D Therapies, Seg14F Disposition|
|● S.13 Financial information||● Seg3 Financial|
|● S.14 Nursing service||● Seg8 Family/Prenatal/Cumulative Health/Medical/Dental Nursing History, Seg14D Therapies|
|● S.15 Health guidance||● Seg10 Care/Treatment Plans and Orders|
|● S.16 Four diagnostic methods in Traditional Chinese medicine||● Seg11 Diagnostic Tests|
The table above demonstrates details of this comparison which indicates certain domains of improvement for future revisions of EHR Standard in China. Detailedly, these deficiencies are listed in the following.
- The lack of supporting on privacy and security. The ISO/TS 18308 specifies "The EHR must support the ethical and legal use of personal information, in accordance with established privacy principles and frameworks, which may be culturally or jurisdictionally specific" (ISO 18308: Health Informatics-Requirements for an Electronic Health Record Architecture, 2004). However this China’s EHR Standard did not achieve any of the fifteen requirements in the subclass of privacy and security.
- The shortage of supporting on different types of data and reference. Considering only ICD-9 is referenced as China’s external international coding systems, other similar systems, such as SNOMED CT in clinical terminology presentation, cannot be considered as familiar for Chinese specialists, which could lead to internationally information-sharing deficiency.
- The lack of more generic and extensible lower level data structures. China’s large and complex EHR Standard was constructed for all medical domains. However, the specific and time-frequent attributes of clinical data elements, value sets and templates identified that this once-for-all purpose cannot lead to practical consequence.
In Hong Kong a computerized patient record system called the Clinical Management System (CMS) has been developed by the Hospital Authority since 1994. This system has been deployed at all the sites of the Authority (40 hospitals and 120 clinics), and is used by all 30,000 clinical staff on a daily basis, with a daily transaction of up to 2 millions. The comprehensive records of 7 million patients are available on-line in the Electronic Patient Record (ePR), with data integrated from all sites. Since 2004 radiology image viewing has been added to the ePR, with radiography images from any HA site being available as part of the ePR.
The Hong Kong Hospital Authority placed particular attention to the governance of clinical systems development, with input from hundreds of clinicians being incorporated through a structured process. The Health Informatics Section in Hong Kong Hospital Authority has close relationship with Information Technology Department and clinicians to develop healthcare systems for the organization to support the service to all public hospitals and clinics in the region.
The Hong Kong Society of Medical Informatics (HKSMI) was established in 1987 to promote the use of information technology in healthcare. The eHealth Consortium has been formed to bring together clinicians from both the private and public sectors, medical informatics professionals and the IT industry to further promote IT in healthcare in Hong Kong.
Since 2010, The Ministry of Health (MoH) working on the Malaysian Health Data Warehouse (MyHDW) project. MyHDW aims to meet the diverse needs of timely health information provision and management, and acts as a platform for the standardization and integration of health data from a variety of sources (Health Informatics Centre, 2013). The Ministry has embarked on introducing the electronic Hospital Information Systems (HIS) in several public hospitals including Serdang Hospital, Selayang Hospital and University Kebangsaan Malaysia Medical Centre (UKMMC) under the Ministry of Higher Education (MOHE).
A Hospital Information System (HIS) is a comprehensive, integrated information system designed to manage the administrative, financial and clinical aspects of a hospital. As an area of Medical Informatics, the aim of hospital information system is to achieve the best possible support of patient care and administration by electronic data processing. HIS plays a vital role in planning, initiating, organizing and controlling the operations of the subsystems of the hospital and thus provides a synergistic organization in the process.
Health Informatics is taught at five New Zealand universities. The most mature and established is the Otago programme which has been offered for over a decade. Health Informatics New Zealand (HINZ), is the national organisation that advocates for Health Informatics. HINZ organises a conference every year and also publishes an online journal- Healthcare Informatics Review Online.
The Saudi Association for Health Information (SAHI) was established in 2006 to work under direct supervision of King Saud bin Abdulaziz University for Health Sciences to practice public activities, develop theoretical and applicable knowledge, and provide scientific and applicable studies.
Post Soviet Countries
The Russian Federation
Russian healthcare system mainly consists of the principles based on the principles of the soviet healthcare system that was oriented on mass prophylaxis, prevention of infection and epidemic diseases, vaccination and immunization of the Soviet population on socially protected basis. Current government Healthcare system consists of several directions:
- Preventive health care
- Primary health care
- Specialized medical care
- Obstetrical and gynecologic medical care
- Pediatric medical care
- Rehabilitation/ Health resort treatment
One of the main issues of the post-soviet medical health care system was the absence of the united system providing optimization of work for medical institutes with one, single database and structured appointment schedule and hence hours-long lines. Efficiency of medical workers might have been also doubtful because of the paperwork administrating or lost book records.
Along with the development of the information systems IT and Healthcare departments of Moscow agreed on designing a system that would improve public services of health care institutes. Tackling with the issues appearing in the current system, Moscow Government ordered the designing of the system that would provide simplified electronic booking to public clinics and automatize work of medical workers on the first level.
The system designed for that purposes was called EMIAS (United Medical Information and Analysis System) and presents EHR (Electronic Health Record) with the majority of other services set in the system that allow managing flows of patients, contains outpatient card integrated in the system, and provides an opportunity to manage consolidated managerial accounting and personalized list of medical help. Besides that, the system contains information about availability of the medical institutions and various doctors.
The beginning of the implementation of the system started in 2013 with the organization of one computerized database for all patients in the city, including convenient front-end for the users. EMIAS is implemented in Moscow and Moscow region and it is planned that the project should embrace most parts of the country.
Health Informatics Law
Health informatics law deals with evolving and sometimes complex legal principles as they apply to information technology in health-related fields. It addresses the privacy, ethical and operational issues that invariably arise when electronic tools, information and media are used in health care delivery. Health Informatics Law also applies to all matters that involve information technology, health care and the interaction of information. It deals with the circumstances under which data and records are shared with other fields or areas that support and enhance patient care.
As many healthcare systems are making an effort to have patient records more readily available to them via the internet, it is important that providers be sure that there are a few security standards in place in order to make sure that the patients information is safe. They have to be able to assure confidentiality and the security of the people, process, and technology. Since there is also the possibility of payments being made through this system, it is vital that this aspect of their private information will also be protected through cryptography.
Worldwide use of computer technology in medicine began in the early 1950s with the rise of the computers. In 1949, Gustav Wagner established the first professional organization for informatics in Germany. The prehistory, history, and future of medical information and health information technology are discussed in reference. Specialized university departments and Informatics training programs began during the 1960s in France, Germany, Belgium and The Netherlands. Medical informatics research units began to appear during the 1970s in Poland and in the U.S. Since then the development of high-quality health informatics research, education and infrastructure has been a goal of the U.S. and the European Union.
Early names for health informatics included medical computing, biomedical computing, medical computer science, computer medicine, medical electronic data processing, medical automatic data processing, medical information processing, medical information science, medical software engineering, and medical computer technology.
The health informatics community is still growing, it is by no means a mature profession, but work in the UK by the voluntary registration body, the UK Council of Health Informatics Professions has suggested eight key constituencies within the domain - information management, knowledge management, portfolio/programme/project management, ICT, education and research, clinical informatics, health records(service and business-related), health informatics service management. These constituencies accommodate professionals in and for the NHS, in academia and commercial service and solution providers.
Leading health informatics and medical informatics journals
- Clinical coder
- Clinical documentation improvement
- Continuity of care record (CCR)
- Diagnosis-related groups
- Electronic health record (EHR)
- Electronic medical record (EMR)
- Health information exchange (HIE)
- Health information management (HIM)
- Hospital information system
- Human resources for health (HRH) information system
- International Classification of Diseases (ICD)
- Medical coding
- Personal health record (PHR)
- Public health informatics
Standards/frameworks and governance
- Health Metrics Network
- Fast Healthcare Interoperability Resources (FHIR)
- Omaha System
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