Medical Informatics: Computer Applications in Health Care

and Biomedicine (Health Informatics)

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 Health Informatics Series
(formerly Computers in Health Care)

Series Editors
Kathryn J. Hannah Marion J. Ball

Dental Informatics
Integrating Technology into the Dental Environment
L.M. Abbey and J. Zimmerman
Ethics and Information Technology
A Case-Based Approach to a Health Care System in Transition
J.G. Anderson and K.W. Goodman
Aspects of the Computer-Based Patient Record
M.J. Ball and M.F. Collen
Performance Improvement Through Information Management
Health Care's Bridge to Success
M.J. Ball and J.V. Douglas
Strategies and Technologies for Healthcare Information
Theory into Practice
M.J. Ball, J.V. Douglas, and D.E. Garets
Nursing Informatics
Where Caring and Technology Meet, Third Edition
M.J. Ball, K.J. Hannah, S.K. Newbold, and J.V. Douglas
Healthcare Information Management Systems
A Practical Guide, Second Edition
M.J. Ball, D.W. Simborg, J.W. Albright, and J.V. Douglas
Healthcare Information Management Systems
Cases, Strategies, and Solutions, Third Edition
M.J. Ball, C.A. Weaver, and J.M. Kiel
Clinical Decision Support Systems
Theory and Practice
E.S. Berner
Strategy and Architecture of Health Care Information Systems
M.K. Bourke
Information Networks for Community Health
P.F. Brennan, S.J. Schneider, and E. Tornquist
Informatics for the Clinical Laboratory
A Practical Guide
D.F. Cowan

(continued after index)

Edward H. Shortliffe Leslie E. Perreault
Editors

Gio Wiederhold Lawrence M. Fagan

Associate Editors

Medical Informatics
Computer Applications
in Health Care and
Biomedicine
Second Edition

With 199 Illustrations

~ Springer
Edward H. Shortliffe, MD, PhD, FACP, FACMI Leslie E. Perreault, MS
Professor and Chair NewYork,NY
Department of Medical Informatics in Medicine USA
Professor of Medicine and Computer Science
Science Vanderbilt Clinic
Columbia University College of
Physicians and Surgeons
Columbia-Presbyterian Medical Center
New York, New York 10032-3720, USA

Gio Wiederhold, PhD, FIEEE, FACM, Lawrence M. Fagan, MD, PhD, FACMI
FACMI Senior Research Scientist and Associate
Emeritus Professor of Computer Science, Director, Stanford Medical Informatics
Electrical Engineering, and Medicine Co-Director, Medical Information
Stanford University Sciences Training Program
Stanford, CA 94305-9040, USA Director, Medical Informatics
Short Course
Stanford University School of Medicine
Stanford, CA 94305-5479, USA
Series Editors:
Kathryn J. Hannah, PhD, RN Marion J. Ball, EdD
Adjunct Professor Department Vice-President, Clinical Solutions
of Community Health Sciences Healthlink, Inc.
Faculty of Medicine Baltimore, MD 21210, USA
The University of Calgary and
Calgary, Alberta, Canada T2N 4Nl Adjunct Professor
Johns Hopkins University School
of Nursing
Baltimore, MD 21205, USA
Library of Congress Cataloging-in-Publication Data
Medical informatics: computer applications in health care and biomedicine / editors, Edward H.
Shortliffe, Leslie E. Perreault; associated editors, Gio Wiederhold, Lawrence M.
Fagan-2nd ed.
p. cm. - (Health informatics series)
Includes bibliographical references and index.
ISBN 978-1-4899-0517-8
1. Medical informatics. 1. Shortliffe, Edward Hance. II. Health informatics.
R858.M397 2000
610'.285-dc21 99-089476
Printed on acid-free paper.
ISBN 978-1-4899-0517-8 ISBN 978-0-387-21721-5 (eBook)
DOI 10.1007/978-0-387-21721-5
© Springer Science+Business Media New York 2001
Originally published by Springer Science+Business Media, Inc. in 2001
Softcover reprint of the hardcover 2nd edition 2001
All rights reserved. This work may not be translated or copied in whole or in part without the written
permission of the publisher Springer Science+Business Media, LLC, except for brief excerpts in con-
nection with reviews or scholarly analysis. Use in connection with any form of information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known
or hereafter developed is forbidden.
The use in this publication of trade names, trademarks, service marks and similar terms, even if they are
not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject
to proprietary rights.
(MPIMVY)
987
springeronline.com
Where is the knowledge we have lost in information?
Where is the wisdom we have lost in knowledge?
-T.S. Elliot, "The Rock"

To the memory of Scott Blois, innovator, philoso-

pher, and scholar, who showed us how to look be-
yond technology to the concepts and perspectives
that help to define the scientific underpinnings for
the field of medical informatics.
Series Preface

This series is directed to healthcare professionals who are leading the transfor-
mation of health care by using information and knowledge. Launched in 1988 as
Computers in Health Care, the series offers a broad range of titles: some ad-
dressed to specific professions such as nursing, medicine, and health adminis-
tration; others to special areas of practice such as trauma and radiology. Still
other books in the series focus on interdisciplinary issues, such as the computer-
based patient record, electronic health records, and networked healthcare
systems.
Renamed Health Informatics in 1998 to reflect the rapid evolution in the dis-
cipline now known as health informatics, the series continues to add titles that
contribute to the evolution of the field. In the series, eminent experts, serving as
editors or authors, offer their accounts of innovations in health informatics. In-
creasingly, these accounts go beyond hardware and software to address the role
of information in influencing the transformation of healthcare delivery systems
around the world. The series also increasingly focuses on "peopleware" and the
organizational, behavioral, and societal changes that accompany the diffusion of
information technology in health services environments.
These changes will shape health services in the new millennium. By making
full and creative use of the technology to tame data and to transform informa-
tion, health informatics will foster the development of the know ledge age in health
care. As co-editors, we pledge to support our professional colleagues and the se-
ries readers as they share advances in the emerging and exciting field of health
informatics.

Kathryn J. Hannah
Marion J. Ball

vii
Preface

Just as banks cannot practice modem banking without financial software, and
airlines cannot manage modem travel planning without shared databanks of flight
schedules and reservations, it has become impossible to practice modem medi-
cine without information technologies. Health professionals recognize that a large
percentage of their activities relates to information management-for example,
obtaining and recording information about patients, consulting colleagues, read-
ing the scientific literature, planning diagnostic procedures, devising strategies
for patient care, interpreting results of laboratory and radiologic studies, or con-
ducting case-based and population-based research. It is complexity and uncer-
tainty, plus society's overriding concern for patient well-being and the resulting
need for optimal decision-making, that set medicine apart from many other in-
formation-intensive fields. Our desire to provide the best possible health and
health care for our society gives a special significance to the effective organiza-
tion and management of the huge bodies of data with which health profession-
als must deal. It also suggests the need for specialized approaches and for skilled
scientists who are knowledgeable about both medicine and information
technologies.

Information Management in Biomedicine

Although the application of computers to biomedicine is recent, the clinical and
research influence of medical-computing systems is already remarkably broad.
Clinical information systems, which provide communication and information-
management functions, are now installed in essentially all healthcare institutions.
Physicians can search entire drug indexes in a few seconds, using the informa-
tion provided by a computer program to anticipate harmful side effects or drug
interactions. Electrocardiograms often are analyzed initially by computer pro-
grams, and similar techniques are being applied for interpretation of pUlmonary-
function tests and a variety of laboratory and radiologic abnormalities. Micro-
processor systems routinely monitor patients and provide warnings in critical-care
settings, such as the intensive-care unit or the operating room. Both biomedical

ix
x Preface

researchers and clinicians regularly use computer programs to search the med-
ical literature, and modem clinical research would be severely hampered with-
out computer-based data-storage techniques and statistical-analysis systems. Ad-
vanced decision-support tools also are emerging from research laboratories, are
being integrated with patient-care systems, and are likely to have a profound ef-
fect on the way medicine is practiced in the future.
Despite this growing use of computers in healthcare settings and the resulting
expansion of interest in learning more about medical computing, many health
students and professionals have found it difficult to obtain a comprehensive and
rigorous, but nontechnical, overview of the field. Both practitioners and basic
scientists are recognizing that thorough preparation for their professional futures
requires that they gain an understanding of the state of the art in biomedical com-
puting, of the current and future capabilities and limitations of the technology,
and of the way in which such developments fit within the scientific, social, and
fmancial context of biomedicine. In turn, the future of the medical-computing
field will be largely determined by how well health professionals and other peo-
ple are prepared to guide the discipline's development. This book is intended to
meet this growing need for well-equipped professionals.
The first edition appeared in 1990 and has been used throughout the world
in courses on medical informatics. Like the first edition, this new version pro-
vides a conceptual framework for learning about computer applications in med-
ical care, for critiquing existing systems, and for anticipating future directions
that the field may take. In many respects, however, this new edition is very dif-
ferent from its predecessor. Most importantly, it reflects the remarkable changes
in computing and communications that have occurred in the past decade. For
example, the Internet was barely mentioned in the first edition, but it and the
World Wide Web are now discussed in almost every chapter in light of their
pervasive societal influence in recent years. In addition, new chapters are in-
cluded, and others have been deleted or revamped. We include new chapters on
bioinformatics, standards development, systems evaluation, technology assess-
ment, legal topics, and ethical considerations. The former chapter on "hospital
information systems" has now given way to a discussion of enterprise comput-
ing for integrated delivery networks. Those who are familiar with the first edi-
tion will find that the organization and philosophy are unchanged, but the con-
tent is almost entirely new.!
This book differs from other introductions to the field in its broad coverage
and in its emphasis on the field's conceptual underpinnings. Our book does not
presume that readers have a health-science or computer-science background, but

lAs in the first edition, the book tends to draw both its examples and its contributors from
North America. There is excellent work in other parts of the world as well, although vari-
ations in healthcare systems, and especially in financing, do tend to change the way in
which systems evolve from one country to the next. The basic concepts are identical, how-
ever, so the book is intended to be useful in educational programs in other parts of the
world as well.
 Preface xi

it does assume that they are interested in a comprehensive summary of the field
that stresses the underlying concepts, and it introduces technical details only to
the extent that they are necessary to meet the principal goal. It thus differs from
an impressive early text in the field (Ledley, 1965) that emphasized technical de-
tails but did not dwell on the broader social and clinical context in which med-
ical computing systems are developed and implemented.

Overview and Guide to Use of This Book

This book is written as a text so that it can be used in formal courses, but we
have adopted a broad view of the population for whom it is intended. Thus, it
may be used not only by students of medicine and of the other health professions
but also by future medical-computing professionals as an introductory text as
well as a text for self-study and for reference by practitioners. The book is prob-
ably too detailed for use in a 2- or 3-day continuing-education course, although
it could be introduced as a reference for further independent study.
Our principal goal in writing this text is to teach concepts in medical informat-
ics-the study of biomedical information and its use in decision-making-and to
illustrate them in the context of descriptions of representative systems that are in
use today or that taught us lessons in the past. As you will see, medical informat-
ics is more than the study of computers in medicine, and we have organized the
book to emphasize this point. Chapter 1 first sets the stage for the rest of the book
by providing a glimpse of the future, defining important terms and concepts, de-
scribing the content of the field, explaining the connections between medical in-
formatics and related disciplines, and discussing the forces that have influenced re-
search in medical informatics and its integration into medical practice.
Broad issues regarding the nature of data, information, and knowledge per-
vade all areas of application, as do concepts related to optimal decision-making.
Chapters 2 and 3 focus on these topics but mention computers only in passing.
They serve as the foundation for all that follows.
Chapters 4 and 5 introduce the central ideas of computer hardware and soft-
ware that are important for understanding the applications described later. Also
included is a discussion of computer-system design, with explanations of im-
portant issues for you to consider when you read about specific applications and
systems throughout the remainder of the book.
Chapter 6 summarizes the issues of standards development, focusing in par-
ticular on data exchange and issues related to sharing of clinical data. This im-
portant and rapidly evolving topic was not covered in our fIrst edition but war-
rants inclusion here given the increasingly central role of standards in enabling
clinical systems to have their desired influence on healthcare practices.
Chapter 7 addresses the key legal and ethical issues that have arisen when
health information systems are considered. Then, in Chapter 8, the challenges
associated with technology assessment and the evaluation of clinical information
systems are introduced.
xii Preface

Chapters 9 through 18 survey many of the key biomedical areas in which com-
puters are being used. Each chapter explains the conceptual and organizational
issues in building that type of system, reviews the pertinent history, and exam-
ines the barriers to successful implementations.
Chapter 19 provides a historical perspective on changes in the way society
pays for health care. It discusses alternative methods for evaluating the costs and
the benefits of health care and suggests ways in which fmancial considerations
affect medical computing. The book concludes in Chapter 20 with a look to the
future-a vision of how informatics concepts, computers, and advanced com-
munication devices one day may pervade every aspect of medical practice.

The Study of Computer Applications in Medicine

The actual and potential uses of computers in medical care form a remarkably
broad and complex topic. Just as you do not need to understand how a telephone
works to make good use of it and to tell when it is functioning poorly, however,
we believe that technical medical-computing skills are not needed by health work-
ers who simply wish to become effective computer users. On the other hand,
such technical skills are of course necessary for individuals with career com-
mitment to developing computer systems for medical environments. Thus, this
book will neither teach you to be a programmer nor show you how to fix a bro-
ken computer (although it might motivate you to learn how to do both). It also
will not tell you about every important medical-computing system or applica-
tion; we shall direct you to a wealth of literature where review articles and in-
dividual project reports can be found. We describe specific systems only as ex-
amples that can provide you with an understanding of the conceptual and
organizational issues to be addressed in building systems for such uses. Exam-
ples also help to reveal the remaining barriers to successful implementations.
Some of the application systems described in the book are well established, even
in the commercial marketplace. Others are just beginning to be used broadly in
biomedical settings. Several are still largely confined to the research laboratory.
Because we wish to emphasize the concepts underlying this field, we gener-
ally limit the discussion of technical implementation details. The computer-
science issues can be learned from other courses and other textbooks. One ex-
ception, however, is our emphasis on the details of decision science as they re-
late to medical problem-solving (Chapters 3 and 16). These topics generally are
not presented in computer-science courses, yet they playa central role in the in-
telligent use of medical data and knowledge. Sections on medical decision-
making and computer-assisted decision support accordingly include more tech-
nical detail than you will find in other chapters.
All chapters include annotated Suggested Readings to which you can turn if
you have a particular interest in a topic, and there is a comprehensive Bibliog-
raphy at the end of the book. We use boldface print to indicate the key terms of
 Preface xiii

each chapter; the definitions of these terms are included in the Glossary at the
end of the book. Because many of the issues in medical informatics are concep-
tual, we have included Questions for Discussion at the end of each chapter. You
will quickly discover that most of these questions do not have "right" answers.
They are intended to illuminate key issues in the field and to motivate you to ex-
amine additional readings and new areas of research.
It is inherently limiting to learn about computer applications solely by reading
about them. We accordingly encourage you to complement your studies by seeing
real systems in use-ideally by using them yourself. Your understanding of system
limitations and of what you would do to improve a medical-computing system will
be greatly enhanced if you have personal experience with representative applica-
tions. Be aggressive in seeking opportunities to observe and use working systems.
In a field that is changing as rapidly as computer science is, it is difficult ever
to feel that you have knowledge that is completely current. The conceptual ba-
sis for study, however, changes much more slowly than do the detailed techno-
logical issues. Thus, the lessons you learn from this volume will provide you
with a foundation on which you can continue to build in the years ahead.

The Need for a Course in Medical

Computing Applications
Suggesting that new courses are needed in the curricula for students of the health
professions does not increase your popularity. If anything, educators and students
have been clamoring for reduced lecture time, for more emphasis on small group
sessions, and for more free time for problem-solving and reflection. A 1984 national
survey by the Association of American Medical Colleges found that both medical
students and their educators severely criticized the current emphasis on lectures and
memorization. Yet the analysis of a panel on the General Professional Education of
the Physician [Association of American Medical Colleges, 1984] specifically iden-
tified medical informatics, including computer applications, as an area in which new
educational opportunities needed to be developed so that physicians would be bet-
ter prepared for the practice of medicine. The report recommended the formation
of new academic units in medical informatics in our medical schools, and subse-
quent studies and reports have continued to stress the importance of the field and
the need for its inclusion in the educational environments of health professionals.
The reason for this strong recommendation is clear: The practice of medicine
is inextricably entwined with the management of information. In the past, practi-
tioners handled medical information through resources such as the nearest hospi-
tal or medical-school library; personal collections of books, journals, and reprints;
ftles of patient records; consultation with colleagues; manual office bookkeeping;
and (all-too-often flawed) memorization. Although all these techniques continue
to be valuable, the computer now offers new methods for fmding, filing, and sort-
ing information: online bibliographic-retrieval systems, including full-text publi-
xiv Preface

cations; personal computers, with database software to maintain personal infor-

mation and reprint files; office-practice and clinical information systems to cap-
ture, communicate, and preserve key elements of the medical record; consultation
systems to provide assistance when colleagues are inaccessible or unavailable;
practice-management systems to integrate billing and receivable functions with
other aspects of office or clinic organization; and other online information re-
sources that help to reduce the pressure to memorize in a field that defies total
mastery of all but its narrowest aspects. With such a pervasive and inevitable role
for computers in clinical practice, and with a growing failure of traditional tech-
niques to deal with the rapidly increasing information-management needs of prac-
titioners, it has become obvious to many people that a new and essential topic has
emerged for study in schools that train medical and other health professionals.
What are less clear are how the subject should be taught and to what extent it
should be left for postgraduate education. We believe that topics in medical com-
puting are best taught and learned in the context of health-science training, which
allows concepts from both medicine and computer science to be integrated.
Medical-computing novices are likely to have only limited opportunities for in-
tensive study of the material once their health-professional training has been com-
pleted.
The format of medical-informatics education is certain to evolve as faculty
members are hired to develop it at more health-science schools and as the em-
phasis on lectures as the primary teaching method diminishes. Computers will
be used increasingly as teaching tools and as devices for communication,
problem-solving, and data sharing among students and faculty. In the meantime,
medical informatics will be taught largely in the classroom setting. This book is
designed to be used in that kind of traditional course, although the Questions for
Discussion also could be used to focus conversation in small seminars and work-
ing groups. As resources improve in schools, integration of medical-computing
topics into clinical experiences also will become more common. The eventual
goal should be to provide instruction in medical informatics whenever this field
is most relevant to the topic the student is studying. This aim requires educa-
tional opportunities throughout the years of formal training, supplemented by
continuing-education programs after graduation.
The goal of integrating medicine and computer science is to provide a mech-
anism for increasing the sophistication of health professionals so that they know
and understand the available resources. They also should be familiar with med-
ical computing's successes and failures, its research frontiers, and its limita-
tions so that they can avoid repeating the mistakes of the past. Study of med-
ical computing also should improve their skills in information management and
problem-solving. With a suitable integration of hands-on computer experience,
computer-based learning, courses in clinical problem-solving, and study of the
material in this volume, health-science students will be well prepared to make
effective use of computer-based tools and information management in health-
care delivery.
 Preface xv

The Need for Specialists in Medical Informatics

As mentioned, this book also is intended to be used as an introductory text in
programs of study for people who intend to make their professional careers in
medical informatics. If we have persuaded you that a course in medical infor-
matics is needed, then the requirement for trained faculty to teach the courses
will be obvious. Some people, however, might argue that a course on this sub-
ject could be taught by a computer scientist who has an interest in medical com-
puting or by a physician who has taken a few computing courses. Indeed, in the
past, most teaching-and research-has been undertaken by faculty trained pri-
marily in one of the fields and later drawn to the other. Today, however, schools
are beginning to realize the need for professionals trained specifically at the in-
terfaces among medicine, computer science, and related disciplines such as sta-
tistics, cognitive science, health economics, and medical ethics. This book out-
lines a first course for students training for careers in the medical-informatics
field. We specifically address the need for an educational experience in which
computing and information-science concepts are synthesized with biomedical is-
sues regarding research, training, and clinical practice. It is the integration of the
related disciplines that traditionally has been lacking in the educational opportu-
nities available to students with career interests in medical informatics. If schools
are to establish such courses and training programs (and there are already a few
examples of each), they clearly need educators who have a broad familiarity with
the field and who can develop curricula for students of the health professions as
well as of engineering and computer science.
The increasing introduction of computing techniques into medical environments
will require that well-trained individuals be available not only to teach students but
also to design, develop, select, and manage the medical-computing systems of to-
morrow. There is a wide range of context-dependent computing issues that people
can appreciate only by working on problems defined by the healthcare setting and
its constraints. The field's development has been hampered because there are rela-
tively few trained personnel to design research programs, to carry out the experi-
mental and developmental activities, and to provide academic leadership in medical
computing. A frequently cited problem is the difficulty a health professional and a
technically trained computer scientist experience when they try to communicate with
one another. The vocabularies of the two fields are complex and have little over-
lap, and there is a process of acculturation to medicine that is difficult for computer
scientists to appreciate through distant observation. Thus, interdisciplinary research
and development projects are more likely to be successful when they are led by peo-
ple who can effectively bridge the medical and computing fields. Such profession-
als often can facilitate sensitive communication among program personnel whose
backgrounds and training differ substantially.
It is exciting to be working in a field that is maturing and that is having a ben-
eficial effect on society. There is ample opportunity remaining for innovation as
new technologies evolve and fundamental computing problems succumb to the
xvi Preface

creativity and hard work of our colleagues. In light of the increasing sophistica-
tion and specialization required in computer science in general, it is hardly sur-
prising that a new discipline should arise at that field's interface with medicine.
This book is dedicated to clarifying the definition and to nurturing the effec-
tiveness of that new discipline: medical informatics.

Edward H. Shortliffe
Leslie E. Perreault
Acknowledgments

When Larry Fagan, Gio Wiederhold, and I decided to compile the first compre-
hensive textbook on medical informatics, none of us predicted the enormity of
the task we were about to undertake. Our challenge was to create a multi-
authored textbook that captured the collective expertise of leaders in the field yet
was cohesive in content and style. The concept for the book was first developed
in 1982. We had begun to teach a course on computer applications in health care
at Stanford University School of Medicine and had quickly determined that there
was no comprehensive introductory text on the subject. Despite several collec-
tions of research descriptions and subject reviews, none had been developed with
the needs of a rigorous introductory course in mind.
The thought of writing a textbook was daunting due to the diversity of topics.
None of us felt he was sufficiently expert in the full range of important subjects
for us to write the book ourselves. Yet we wanted to avoid putting together a
collection of disconnected chapters containing assorted subject reviews. Thus,
we decided to solicit contributions from leaders in the respective fields to be rep-
resented but to provide organizational guidelines in advance for each chapter.
We also urged contributors to avoid writing subject reviews but, instead, to fo-
cus on the key conceptual topics in their field and to pick a handful of examples
to illustrate their didactic points.
As the draft chapters began to come in, we realized that major editing would
be required if we were to achieve our goals of cohesiveness and a uniform ori-
entation across all the chapters. We were thus delighted when, in 1987, Leslie
Perreault, a graduate of our training program, assumed responsibility for re-
working the individual chapters to make an integral whole and for bringing the
project to completion. The fmal product, published in 1990, was the result of
many compromises, heavy editing, detailed rewriting, and numerous iterations.
We were gratified by the positive response to the book when it fmally appeared
and especially by the students of medical informatics who have often come to
us at scientific meetings and told us about their appreciation of the book.
As the 1990s progressed, however, we began to realize that, despite our em-
phasis on basic concepts in the field (rather than a survey of existing systems),
the volume was beginning to show its age. A great deal had changed since the

xvii
xviii Acknowledgments

initial chapters were written, and it became clear that a new edition would be re-
quired. The original editors discussed the project and decided to redesign the
book, solicit updated chapters, and publish a new edition. Leslie Perreault by this
time was a busy Director at First Consulting Group in New York City and would
not have as much time to devote to the project as she had when we did the fIrst
edition. With trepidation, in light of our knowledge of the work that would be
involved, we embarked on the new project.
As before, the chapter authors have done a marvelous job, trying their best to
meet our deadlines, putting up with editing changes that were designed to bring
a uniform style to the book, and contributing excellent chapters that nicely re-
flect the changes in the fIeld in the last decade. Weare all extremely apprecia-
tive of their commitment and for the excellence of their work on behalf of the
book and the fIeld.
The completed volume reflects the work and support of many people in addi-
tion to the editors and chapter authors. Particular gratitude is once again owed
to Lyn Dupre, our developmental editor, whose rigorous attention to detail is re-
flected on every page. We also appreciate the kindness and professionalism of
Peter Gordon from Addison-Wesley, who worked with us to effect a smooth tran-
sition in the transfer of the book to a new publisher for the second edition. At
Springer-Verlag we have been delighted to work with the responsible editors,
fIrst with Bill Day and, more recently, with Nhora Cortes-Comerer. Marion Ball
and Kathy Hannah have also been extremely supportive in working with us to
move this volume into their Springer-Verlag informatics series.
Members of the administrative staff in our group at Stanford have also been
remarkably supportive during what has at times been an exhausting and time-
consuming process. Rosalind Ravasio competently managed the administrative
details so that we could attend to our writing and editing. We are also grateful
for the support of the Computing Resources Group at Stanford Medical Infor-
matics. Under the direction of Farhad Shafabaksh, the Computing Resources
Group maintains a smoothly functioning computing environment that has been
crucial to the production of this book in its electronic format and to the distrib-
ution of chapters and revisions among the authors and editors via the World Wide
Web.
The unsung hero of the effort is our assistant, Barbara Morgan, who has shoul-
dered the lion's share of the burden for online editing of the chapters, maintain-
ing a system for keeping track of new versions, managing permissions and fIg-
ures, and somehow keeping a good natured disposition throughout it all. We are
all sincerely grateful to Barbara for accepting this new set of responsibilities-
clearly not in her job description-and doing a marvelous job in ushering this
volume to a successful completion. Thank you, Barbara!

Edward H. Shortliffe
Leslie E. Perreault
Contents

Series Preface vii

Preface ix
Acknowledgments xvii
Contributors xxiii

UNIT I RECURRENT THEMES IN MEDICAL

INFORMATICS

CHAPTER 1 The Computer Meets Medicine and Biology:

Emergence of a Discipline 3
Edward H. Shortliffe and Marsden S. Blois

CHAPTER 2 Medical Data: Their Acquisition, Storage, and Use 41

Edward H. Shortliffe and G. Octo Barnett

CHAPTER 3 Medical Decision-Making: Probabilistic

Medical Reasoning 76
Douglas K. Owens and Harold C. Sox

CHAPTER 4 Essential Concepts for Medical Computing 132

Gio Wiederhold and Thomas C. Rindfleisch

CHAPTER 5 System Design and Engineering 180

Gio Wiederhold and Edward H. Shortliffe

CHAPTER 6 Standards in Medical Informatics 212

W. Edward Hammond and James J. Cimino

CHAPTER 7 Ethics and Health Informatics: Users, Standards,

and Outcomes 257
Kenneth W. Goodman and Randolph A. Miller

xix
xx Contents

CHAPTER 8 Evaluation and Technology Assessment 282

Charles P. Friedman, Douglas K. Owens, and Jeremy C. Wyatt

UNIT IT MEDICAL COMPUTING APPLICATIONS

CHAPTER 9 Computer-Based Patient-Record Systems 327
Paul C. Tang and Clement J. McDonald

CHAPTER 10 Management of Information in Integrated

Delivery Networks 359
Charles Safran and Leslie E. Perreault

CHAPTER 11 Public Health and Consumer Uses of Health Information:

Education, Research, Policy, Prevention, and
Quality Assurance 397
Patricia Flatley Brennan and Andrew Friede

CHAPTER 12 Patient-Care Systems 421

Judy G. Ozbolt and Suzanne Bakken

CHAPTER 13 Patient-Monitoring Systems 443

Reed M. Gardner and M. Michael Shabot

CHAPTER 14 Imaging Systems 485

Robert A. Greenes and James F. Brinkley

CHAPTER 15 Information-Retrieval Systems 539

William R. Hersh, William M. Detmer, and Mark E. Frisse

CHAPTER 16 Clinical Decision-Support Systems 573

Mark A. Musen, Yuval Shahar, and Edward H. Shortliffe

CHAPTER 17 Computers in Medical Education 610

Parvati Dev, Edward P. Hoffer, and G. Octo Barnett

CHAPTER 18 Bioinformatics 638

Russ B. Altman

UNIT m MEDICAL INFORMATICS IN THE

YEARS AHEAD

CHAPTER 19 Health Care and Information Technology:

Growing Up Together 663
Sara J. Singer, Alain C. Enthoven, and Alan M. Garber
 Contents xxi

CHAPTER 20 The Future of Computer Applications in Health Care 697

Lawrence M. Fagan and Edward H. Shortlijfe

Bibliography 713
Glossary 749
Name Index 821
Subject Index 831
Contributors

Russ B. Altman, MD, PhD, FACP, FACMI

Associate Professor of Medicine and of Computer Science, Stanford University
School of Medicine, Stanford, CA 94305-5479, USA ([email protected])

Suzanne Bakken, RN, DNSc, FAAN, FACMI

Alumni Professor of Nursing and Professor of Biomedical Informatics,
Columbia University, New York, NY 10032, USA
([email protected])

G. Octo Barnett, MD, FACP, FACMI

Professor of Medicine, Harvard Medical School, Director, Laboratory of
Computer Science, Massachusetts General Hospital, Boston, MA 02114, USA
([email protected])

Marsden S. Blois, MD, PhD, FACMP

Formerly Professor of Medical Informatics and of Dermatology, University of
California, San Francisco, CA, USA

Patricia Flatley Brennan, RN, PhD, FAAN, FACMI

Lillian S. Moehlman Bascom Professor, School of Nursing and College of
Engineering, University of Wisconsin-Madison, Madison, WI 53706, USA
([email protected])

James F. Brinkley, MD, PhD, FACMI

Research Professor of Biological Structure, Computer Science and Engineer-
ing, and Medical Education and Biomedical Informatics, University of Wash-
ington, Seattle, Washington 98195, USA ([email protected])

James J. Cimino, MD, FACP, FACMI

Professor of Biomedical Informatics and Medicine, Columbia University Col-
lege of Physicians and Surgeons, Columbia-Presbyterian Medical Center, New
York, New York 10032, USA ([email protected])

tDeceased

xxiii
xxiv Contributors

William M. Detmer, MD, MS, FACP

President and Chief Executive Officer, Unbound Medicine, Inc., Char-
lottesville, VA 22902, Clinical Assistant Professor, Department of Health
Evaluation Sciences, University of Virginia, Health Sciences Center, Char-
lottesville, VA 22908, USA ([email protected])

Parvati Dev, PhD, FACMI

Director, SUMMIT Laboratory, and Senior Research Scientist, Stanford
Medical Informatics, Stanford University School of Medicine, Stanford,
CA 94305-5466, USA ([email protected])

Alain C. Enthoven, PhD

Senior Fellow, Institute for International Studies, Center for Health Policy,
Marriner S. Eccles Professor of Public and Private Management (Emeritus),
Graduate School of Business, Stanford University, Stanford CA 94305-5015,
USA ([email protected])

lAwrence M. Fagan, MD, PhD, FACMI

Senior Research Scientist and Associate Director, Stanford Medical
Informatics, Co-Director, Biomedical Information Sciences Training Program,
Director, Medical Informatics Short Course, Stanford University School of
Medicine, Stanford, CA 94305-5479, USA ([email protected])

Andrew Friede, MD, MPH

Vice President for Health Mfairs, Analytical Sciences, Inc., Atlanta GA 30329
([email protected])

Charles P. Friedman, PhD, FACMI

Professor of Medicine and Director, Center for Biomedical Informatics, Uni-
versity of Pittsburgh, Pittsburgh, PA 15213-2582, USA ([email protected])

Mark E. Frisse, MD, MS, MBA, FACMI

Vice President, First Consulting Group, Chicago, IL 60606 ([email protected])

Alan M. Garber, MD, PhD, FACP

Professor of Medicine, Economics, and Health Research and Policy, Director,
Center for Primary Care and Outcomes Research, Director, Center for Health
Policy, Stanford University, Stanford, CA 94305-6019, USA
([email protected])

Reed M. Gardner, PhD, FACMI

Professor and Chair, Department of Medical Informatics, University of Utah,
Co-Director of Medical Informatics, LDS Hospital, School of Medicine, Salt
Lake City, UT 84132, USA ([email protected])
 Contributors xxv

Kenneth W. Goodman, PhD

Director, Forum for Bioethics and Philosophy, University of Miami
Miami, FL 33101, USA ([email protected])

Robert A. Greenes, MD, PhD, FACR, FACMI

Professor of Radiology, Harvard Medical School, Professor of Health Sciences
and Technology, Harvard-MIT Division of Health Sciences and Technology,
Professor of Health Policy and Management, Harvard School of Public Health,
Radiologist, Brigham and Women's Hospital,
Director, Decision Systems Group, Brigham and Women's Hospital, Boston,
MA 02115, USA ([email protected])

W. Edward Hammond, PhD, FACMI

Adjunct Professor, Fuqua School of Business, Professor Emeritus, Department
of Community and Family Medicine, Professor Emeritus, Department of Bio-
medical Engineering, Pratt School of Engineering, Duke University, Durham,
NC 27710, USA ([email protected])

William R. Hersh, MD, FACP, FACMI

Professor and Head, Division of Medical Informatics & Outcomes Research,
Oregon Health & Science University, Portland, OR 97201, USA
([email protected])

Edward P. Hoffer MD, FACP, FACC, FRCP(C), FACMI

Associate Professor of Medicine, Harvard Medical School, Senior Scientist
and Assistant Director, Laboratory of Computer Science, Massachusetts Gen-
eral Hospital, Boston, MA 02114, USA ([email protected])

Clement J. McDonald, MD, FACP, FACMI

Director, Regenstrief Institute, Regenstrief Professor of Medical Informatics,
and Distinguished Professor of Medicine, Indiana University School of
Medicine, Indianapolis, IN 46202, USA ([email protected])

Randolph A. Miller, MD, FACMI

Professor and Chairman, Division of Biomedical Informatics, Vanderbilt
University Medical Center, Nashville, TN 37232-8340, USA
(randy [email protected])

Mark A. Musen, MD, PhD, FACP, FACMI

Professor of Medicine and of Computer Science, Head, Stanford Medical
Informatics, Stanford University School of Medicine, Stanford, CA 94305-
5479, USA ([email protected])
xxvi Contributors

Douglas K. Owens, MD, MS

Senior Investigator, Center for Health Care Evaluation, VA Health Care
System, Palo Alto and Associate Professor of Medicine and of Health
Research and Policy, Center for Primary Care and Outcomes Research,
Stanford University, Stanford, California 94305-6019, USA
(owens@ stanford.edu)

Judy G. Ozbolt, PhD, RN, FAAN, FACMI

Independence Foundation Professor of Nursing and Professor of Biomedical
Informatics, Vanderbilt University, Nashville, TN 37240-0008, USA
Gudy [email protected])

Leslie E. Perreault, MS
Consultant, New York, NY USA ([email protected])

Thomas C. Rindfleisch, MS, FACMI

Director Emeritus, Lane Medical Library, Stanford University School of
Medicine, Stanford, CA 94305-5123, USA ([email protected])

Charles Safran, MD, MS, FACP, FACMI

Associate Clinical Professor of Medicine, Harvard Medical School, Chief Ex-
ecutive Officer, Clinician Support Technology, Newton, MA 02459, USA
([email protected])

M. Michael Shabot, MD, FACMI

Associate Director of Surgery and Director, Surgical Critical Care, Cedars-
Sinai Medical Center, Los Angeles, CA 90048, USA ([email protected])

Yuval Shahar, MD, PhD

Associate Professor, Information Systems Engineering, Head, Medical Infor-
matics Research Center, Head, Graduate Program, Information Systems Engi-
neering, Ben Gurion University, Beer-Sheva 84105, Israel
([email protected])

Edward H. Shortliffe, MD, PhD, MACP, FACMI

Professor and Chair, Department of Biomedical Informatics, Professor of Medi-
cine and of Computer Science, Deputy Vice President for Information Technol-
ogy, Health Sciences Division, Columbia University, New York, NY 10032-
3720, USA ([email protected])

Sara J. Singer, MBA

Lecturer, Public Policy Program, Executive Director, Center for Health Policy,
Senior Research Scholar, Institute for International Studies, Stanford Univer-
sity, Stanford, CA 94305-6019, USA ([email protected])