UNIT II

Artificial intelligence in health care: Use of AI, The healthcare industry, Electronic
medical records, Clinical decision support systems.

2.1 ARTIFICIAL INTELLIGENCE IN HEALTH CARE

Artificial intelligence (AI) and related technologies are increasingly prevalent in business and
society, and are beginning to be applied to healthcare. These technologies have the potential to
transform many aspects of patient care, as well as administrative processes within provider,
payer and pharmaceutical organisations.
There are already a number of research studies suggesting that AI can perform as well
as or better than humans at key healthcare tasks, such as diagnosing disease. Today, algorithms
are already outperforming radiologists at spotting malignant tumours, and guiding researchers
in how to construct cohorts for costly clinical trials. However, for a variety of reasons, we
believe that it will be many years before AI replaces humans for broad medical process
domains. In this article, we describe both the potential that AI offers to automate aspects of
care and some of the barriers to rapid implementation of AI in healthcare.
The use of artificial intelligence in healthcare has the potential to assist healthcare
providers in many aspects of patient care and administrative processes.
Most AI and healthcare technologies have strong relevance to the healthcare field, but the
tactics they support can vary significantly.
And while some articles on artificial intelligence in healthcare suggest that the use of
artificial intelligence in healthcare can perform just as well or better than humans at certain
procedures, such as diagnosing disease, it will be a significant number of years before AI in
healthcare replaces humans for a broad range of medical tasks.

What is artificial intelligence in healthcare, and what are the benefits?

Machine Learning
Natural Language Processing
Rule-based Expert Systems
Diagnosis and Treatment Applications
Administrative Applications
 Types of AI of relevance to healthcare
Artificial intelligence is not one technology, but rather a collection of them. Most of
these technologies have immediate relevance to the healthcare field, but the specific processes
and tasks they support vary widely. Some particular AI technologies of high importance to
healthcare are defined and described below.

Machine learning – neural networks and deep learning

Machine learning is a statistical technique for fitting models to data and to ‘learn’ by
training models with data. Machine learning is one of the most common forms of AI; in a 2018
Deloitte survey of 1,100 US managers whose organisations were already pursuing AI, 63% of
companies surveyed were employing machine learning in their businesses.1 It is a broad
technique at the core of many approaches to AI and there are many versions of it.

In healthcare, the most common application of traditional machine learning is precision

medicine – predicting what treatment protocols are likely to succeed on a patient based on
various patient attributes and the treatment context.2 The great majority of machine learning
and precision medicine applications require a training dataset for which the outcome variable
(eg onset of disease) is known; this is called supervised learning.

A more complex form of machine learning is the neural network – a technology that
has been available since the 1960s has been well established in healthcare research for several
decades3 and has been used for categorisation applications like determining whether a patient
will acquire a particular disease. It views problems in terms of inputs, outputs and weights of
variables or ‘features’ that associate inputs with outputs. It has been likened to the way that
neurons process signals, but the analogy to the brain's function is relatively weak. The most
complex forms of machine learning involve deep learning, or neural network models with
many levels of features or variables that predict outcomes. There may be thousands of hidden
features in such models, which are uncovered by the faster processing of today's graphics
processing units and cloud architectures. A common application of deep learning in healthcare
is recognition of potentially cancerous lesions in radiology images.4 Deep learning is
increasingly being applied to radiomics, or the detection of clinically relevant features in
imaging data beyond what can be perceived by the human eye.5 Both radiomics and deep
learning are most commonly found in oncology-oriented image analysis. Their combination
appears to promise greater accuracy in diagnosis than the previous generation of automated
tools for image analysis, known as computer-aided detection or CAD.

Deep learning is also increasingly used for speech recognition and, as such, is a form
of natural language processing (NLP), described below. Unlike earlier forms of statistical
analysis, each feature in a deep learning model typically has little meaning to a human observer.
As a result, the explanation of the model's outcomes may be very difficult or impossible to
interpret.

Natural language processing

Making sense of human language has been a goal of AI researchers since the 1950s.
This field, NLP, includes applications such as speech recognition, text analysis, translation and
other goals related to language. There are two basic approaches to it: statistical and semantic
NLP. Statistical NLP is based on machine learning (deep learning neural networks in
particular) and has contributed to a recent increase in accuracy of recognition. It requires a
large ‘corpus’ or body of language from which to learn.

In healthcare, the dominant applications of NLP involve the creation, understanding

and classification of clinical documentation and published research. NLP systems can analyse
unstructured clinical notes on patients, prepare reports (eg on radiology examinations),
transcribe patient interactions and conduct conversational AI.

Rule-based expert systems

Expert systems based on collections of ‘if-then’ rules were the dominant technology for
AI in the 1980s and were widely used commercially in that and later periods. In healthcare,
they were widely employed for ‘clinical decision support’ purposes over the last couple of
decades5 and are still in wide use today. Many electronic health record (EHR) providers furnish
a set of rules with their systems today.

Expert systems require human experts and knowledge engineers to construct a series of
rules in a particular knowledge domain. They work well up to a point and are easy to
understand. However, when the number of rules is large (usually over several thousand) and
the rules begin to conflict with each other, they tend to break down. Moreover, if the knowledge
domain changes, changing the rules can be difficult and time-consuming. They are slowly
being replaced in healthcare by more approaches based on data and machine learning
algorithms.

Physical robots
Physical robots are well known by this point, given that more than 200,000 industrial
robots are installed each year around the world. They perform pre-defined tasks like lifting,
repositioning, welding or assembling objects in places like factories and warehouses, and
delivering supplies in hospitals. More recently, robots have become more collaborative with
humans and are more easily trained by moving them through a desired task. They are also
becoming more intelligent, as other AI capabilities are being embedded in their ‘brains’ (really
their operating systems). Over time, it seems likely that the same improvements in intelligence
that we've seen in other areas of AI would be incorporated into physical robots.

Surgical robots, initially approved in the USA in 2000, provide ‘superpowers’ to

surgeons, improving their ability to see, create precise and minimally invasive incisions, stitch
wounds and so forth.6 Important decisions are still made by human surgeons, however.
Common surgical procedures using robotic surgery include gynaecologic surgery, prostate
surgery and head and neck surgery.

Robotic process automation

This technology performs structured digital tasks for administrative purposes, ie those
involving information systems, as if they were a human user following a script or rules.
Compared to other forms of AI they are inexpensive, easy to program and transparent in their
actions. Robotic process automation (RPA) doesn't really involve robots – only computer
programs on servers. It relies on a combination of workflow, business rules and ‘presentation
layer’ integration with information systems to act like a semi-intelligent user of the systems. In
healthcare, they are used for repetitive tasks like prior authorisation, updating patient records
or billing. When combined with other technologies like image recognition, they can be used to
extract data from, for example, faxed images in order to input it into transactional systems.

Diagnosis and Treatment Applications

• Diagnosis and treatment of disease has been at the core of artificial intelligence AI in
healthcare for the last 50 years.
 • Early rule-based systems had potential to accurately diagnose and treat disease, but
were not totally accepted for clinical practice.
• They were not significantly better at diagnosing than humans, and the integration was
less than ideal with clinician workflows and health record systems.

Administrative Applications
• There are a number of administrative applications for artificial intelligence in
healthcare.
• The use of artificial intelligence in hospital settings is somewhat less game changing in
this area as compared to patient care.
• But artificial intelligence in hospital administrative areas can provide substantial
efficiencies.
• AI in healthcare can be used for a variety of applications, including claims processing,
clinical documentation, revenue cycle management and medical records management.
• Another use of artificial intelligence in healthcare applicable to claims and payment
administration is machine learning, which can be used for pairing data across different
databases

2.1.2 IMPORTANCE OF AI IN HEALTHCARE SECTOR

AI and related advancements are progressively playing the role of a disruptor in business and
society. The application of AI is also increasing in the healthcare domain. These advances can
possibly change numerous parts of patient care, just as regulatory procedures inside supplier,
patient experience, and pathology labs. There are as of now various researches recommending
that AI can proceed just as or better than people at key human services, for example, diagnosing
the ailment.

Nonetheless, for an assortment of reasons, have to accept that it will be numerous prior years
AI replaces people for wide clinical procedure areas. In this article, we portray both the
potential that AI offers to mechanize parts of care and a portion of the hindrances to the fast
execution of AI in social insurance.
How about we talk about how AI has changed the Healthcare segment:
2.1.3 AI in Healthcare

Fig1 Role of AI
1. Early Detection of ailments
AI-based knowledge is now used to recognize illnesses, for instance, tumors, in their starting
stage. According to the American Cancer Society, a high degree of mammograms yield
counterfeit results. 1 out of 2 sound women was prone to threatening development.
The use of AI is engaging study and understanding of mammograms on different
occasions speedier with 99% precision, diminishing the necessity for silly biopsies. The
widespread use of wearables like iWatch by Apple and other clinical contraptions got together
with AI. This helps in overseeing starting period coronary ailment. In general, the earlier the
detection of a disease, the better it can be treated.
2. Improve Decision Making
Improving thought requires the course of action of gigantic prosperity data with reasonable and
perfect decisions, and insightful assessment can reinforce clinical elements and exercises
similarly as sort out administrative endeavors.

Using past information of patients to recognize patients at risk for a condition is one of the
major uses of AI in healthcare. Using this information, AI algorithms can assist in better and
improved decision-making processes.
3. Help in Treatment
By looking at the previous medical records of patients, AI can help individuals who are at a
greater risk of medical conditions like heart stroke. AI can help clinicians with devising better
treatment plans for these patients.

We use Robots in the prescription for more than 30 years. Despite clinical strategies, we use
them in crisis facilities and labs for excess tasks, in recuperation, non-nosy treatment, and on
those with long stretch conditions.

4. End of Life Care

With time, the future of a normal human has impressively expanded because of better social
insurance offices. Presently, as we approach the finish of our lives, our body capitulates to
death in a slower way, from conditions like dementia, cardiovascular breakdown, and
osteoporosis.

Robots can modify the finish of life care, helping people to remain self-ruling for additional,
reducing the necessity for hospitalization and care homes. In this way, AI can help to make the
experience better for critically ill or old age patients.

5. Associated Care
Healthcare doesn’t just mean treatment by doctors. It involves a lot of hospital staff, nurses,
managers, technicians, and pharmacists to efficiently run this entire healthcare ecosystem. To
improve healthcare, this whole ecosystem has to evolve.

These zones rely upon a lone propelled structure. Concentrated war rooms dismember clinical
and zone data to screen showcase enthusiasm over the framework persistently. Similarly, as
using AI to spot patients at risk for deterioration, this framework can in like manner remove
bottlenecks in the system.

6. Giving a superior experience

Similarly, as with some other industry, in the social insurance industry likewise, the client
experience, just as the staff understanding, is of most extreme significance for their drawn-out
development.
Computer-based and intelligence-based frameworks are being created for helping with
decreasing hold up times, improving staff work procedures, and taking on the ever-creating
administrative weight.

The more that AI is used in clinical practice, the more clinicians are creating to trust in it to
build their aptitudes in zones, for instance, clinical methodology and end.

7. Checking Health Through Wearables

Essentially all clients by and by approach devices with sensors that can accumulate significant
data about their prosperity. Devices like FitBit and IWatch by Apple have become an
increasingly useful gadget. They help to track our daily calorie count, steps, and even sleeping
pattern.

Using this data, analyzing it with the help of AI, can bring a lot of awareness among individuals
and help them keep a better track of their fitness. Man-made intelligence frameworks will
accept an important activity in isolating huge bits of information from this tremendous and
contrasted treasure trove of data.

8. Expanded Access to Medical Services

Lacks of arranged human administration providers, including ultrasound experts and
radiologists would altogether be able to limit access to life-saving thought in making nations
around the world.

More radiologists work in the around six clinical centers covering the prominent Longwood
Avenue in Boston than in all of West Africa, the gathering pointed out.

Modernized thinking could help moderate the impacts of this extraordinary deficiency of
qualified clinical staff by accepting authority over a segment of the suggestive commitments
usually doled out to individuals.

Future of AI in Healthcare
all must accept that there is a significant role of AI in the healthcare sector in the coming years.
Like AI, it is the essential ability behind the improvement of precise medication, broadly
consented to be a painfully required development in care.
Albeit early endeavors at giving analysis and treatment proposals have demonstrated testing,
we expect that AI will at last ace that area also. Given the fast advances in AI for imaging
examination, most radiology and pathology pictures will be analyzed sooner or later by a
machine. Discourse and content acknowledgment is now utilized for errands like patient
correspondence and catch of clinical notes, and their use will increment.

The best test to AI in these social insurance spaces isn’t whether the advances will be able
enough to be helpful, but instead guaranteeing their reception in every day clinical practice.
For broad appropriation to occur, AI frameworks must be endorsed by controllers.
They must also incorporate EHR frameworks. Thus, we hope to see constrained utilization of
AI in clinical practice inside 5 years and increasingly broad use inside 10 years.
It additionally appears to be progressively certain that AI frameworks won’t supplant human
clinicians for an enormous scope, yet rather will expand their endeavors to think about patients.
After some time, human clinicians may push toward undertakings and employment plans that
draw on remarkably human abilities like compassion, influence, and enormous picture joining.

2.2 THE HEALTHCARE INDUSTRY

The purpose of the health care industry is to promote health, to heal, to provide treatment,
and to increase the quality of life of the individuals that are being served. Each medical
professional has chosen to pursue a career to help mankind, in a selfless act and without self-
interest.
Healthcare comprises hospitals, medical devices, clinical trials, outsourcing, telemedicine,
medical tourism, health insurance and medical equipment. The Indian healthcare sector is
growing at a brisk pace due to its strengthening coverage, services and increasing expenditure
by public as well private players.

Sectors of Healthcare Industry

The healthcare industry provides a variety of services to support the healthcare needs of a
community or individuals. A universally agreed-upon classification of sectors does not exist,
but the key sectors of the healthcare industry can be broadly classified into four sectors called
'Health care services and facilities', 'Medical devices, equipment, and hospital supplies
manufacturers', Medical insurance, medical services and managed care' and 'Pharmaceuticals
& Related Segments
Healthcare Industry Sectors:

The healthcare industry provides a variety of services to support the healthcare needs of a
community or individuals. The healthcare industry classifies the different products it offers by
sector. Hospitals and healthcare systems are continually changing their service offerings and
responding to various internal and external forces including reimbursement issues, advances in
technology, and shifts in the populations they serve. A universally agreed-upon classification
of sectors does not exist, so a non-exhaustive but the inclusive and simplified classification of
broad sectors will be used in this exploration.
The key sectors of the healthcare industry can be broadly classified into the following four sub-
segments:

1. Health care services and facilities

2. Medical devices, equipment, and hospital supplies manufacturers
3. Medical insurance, medical services, and managed care
4. Pharmaceuticals & Related Segments

Healthcare Segment 1: Health care services and facilities:

Health care services and facilities subsector is comprised of many subsectors. The broad
classification includes:

(A) Hospitals:

Hospitals provide medical, diagnostic, and treatment services to inpatients and some outpatient
services. This category includes General medical and surgical hospitals, psychiatric and
substance abuse hospitals, Specialty hospitals (not including psychiatric and substance abuse
facilities), Family Planning & Abortion Clinics, Hospices & Palliative Care Centers,
Emergency & Other Outpatient Care Centers, Sleep Disorder Clinics, Dental Laboratories, and
Blood & Organ Banks.

Given below are different types of hospitals:

 • General medical and surgical hospitals
• Psychiatric and substance abuse hospitals
• Specialty hospitals (not including psychiatric and substance abuse facilities)
• Family Planning & Abortion Clinics
• Hospices & Palliative Care Centers
• Emergency & Other Outpatient Care Centers
• Sleep Disorder Clinics
• Dental Laboratories
• Blood & Organ Banks
• Teaching or University Hospitals

(B) Nursing and residential care facilities:

They provide residential care combined with either nursing, supervisory, or other types of care
as needed. This category includes Home health care services, Nursing Care Facilities, Urgent
Care Centers, Mental health and residential developmental handicap facilities, In-Home Senior
Care, Community care facilities for the elderly, and other residential care facilities.

Given below are different nursing and residential care facilities:

• Home health care services

• Nursing Care Facilities
• Urgent Care Centers
• Mental health and residential developmental handicap facilities
• In-Home Senior Care
• Community care facilities for the elderly
• Other residential care facilities

(C) Ambulatory health care services:

Players provide direct and indirect health care services to ambulatory patients. This category
includes Outpatient care centers, medical and diagnostic laboratories, Ambulance Services, and
other ambulatory health care services.
Given below are different ambulatory health care services:

• Outpatient care centers

• Medical and diagnostic laboratories
• Ambulance Services
• Other ambulatory health care services

(D) Medical Practitioners & Healthcare Professionals:

This category includes Medical Practitioners, Chiropractors, Homeopaths, Psychologists,

Social Workers & Marriage Counselors, Dermatologists, Nutritionists & Dietitians,
Optometrists, Physical Therapists, and other alternative Healthcare Providers.

Given below are different types of Medical Practitioners and healthcare professionals:

• Medical Practitioners
• Chiropractors
• Homeopaths
• Psychologists, Social Workers & Marriage Counselors
• Dermatologists
• Nutritionists & Dietitians
• Optometrists
• Physical Therapists
• Alternative Healthcare Providers

Healthcare Segment 2: Medical devices, equipment, and hospital supplies manufacturers:

These are medical companies at the forefront of the latest medical technology offering their
products across the whole spectrum of medical equipment, hospital supplies, products, and
services, including specialist applications. This sector further consists of many players
including In-vitro diagnostic substances, Electro-medical and electrotherapeutic apparatuses ,
Irradiation apparatuses, Surgical Instrument & Medical Instrument Manufacturing, Surgical
appliances and supplies, Dental equipment and supplies, Ophthalmic goods, Vital Signs
Monitor Manufacturing, Mammography Machine Manufacturing, TENS Machine
Manufacturing, Nebulizer Manufacturing, Hot & Cold Topical Therapy Manufacturing,
Optical Coherence Tomography Machine Manufacturing, Medical Laser Machine
Manufacturing, Medical Device Manufacturing, Medical Instrument & Supply Manufacturing,
Robotic Surgery Equipment Manufacturing, Endoscope Manufacturing, Venous Access
Device Manufacturing, Wound Care Product Manufacturing, Toxicology Laboratories,
Glucose Meter Manufacturing, Instrument Sterilization Product Manufacturing, Intravenous
(IV) Solution Manufacturing, Ultrasonic Cleaning Equipment Manufacturing, Hospital Bed
Manufacturing and Hospital Furniture Manufacturing etc.

Given below are different Medical devices, equipment, and hospital supplies manufacturers:

• In-vitro diagnostic substances

• Electro-medical and electrotherapeutic apparatuses
• Irradiation apparatuses
• Surgical Instrument & Medical Instrument Manufacturing
• Surgical appliances and supplies
• Dental equipment and supplies
• Ophthalmic goods
• Vital Signs Monitor Manufacturing
• Mammography Machine Manufacturing
• TENS Machine Manufacturing
• Nebulizer Manufacturing
• Hot & Cold Topical Therapy Manufacturing etc

• Healthcare Segment 3: Medical insurance, medical services, and managed care:

This segment deals with the players that provide medical insurance or different types of
services to either patients or other medical sector players. The term managed care or managed
health care is used to describe a variety of techniques intended to reduce the cost of providing
health benefits and improve the quality of care for organizations that use those techniques or
provide them as services to other organizations. This sector further consists of many players
including Health maintenance organizations (HMOs), Preferred provider organizations,
exclusive provider organizations, Medicare, Medicaid, Healthcare Consultants, Medical
Patient Financing, Healthcare Staff Recruitment Agencies, Health & Medical Insurance,
Surgical Apparel Manufacturing, Medical Supplies Wholesaling, Medical Waste Disposal
Services, Dental Insurance, Medical Couriers, Medical Device Cleaning & Recycling, Medical
Claims Processing Services, Pharmacy Benefit Management, Corporate Wellness Services,
Home Medical Equipment Rentals and Medical Case Management Services, etc.

Given below are different medical insurance, medical services, and managed care providers:

• Health maintenance organizations (HMOs)

• Preferred provider organizations
• Exclusive provider organizations
• Medicare
• Medicaid
• Healthcare Consultants
• Medical Patient Financing
• Healthcare Staff Recruitment Agencies
• Health & Medical Insurance
• Surgical Apparel Manufacturing
• Medical Supplies Wholesaling
• Medical Waste Disposal Services
• Dental Insurance
• Medical Couriers
• Medical Device Cleaning & Recycling
• Medical Claims Processing Services
• Pharmacy Benefit Management
• Corporate Wellness Services
• Home Medical Equipment Rentals
• Medical Case Management Services

Healthcare Segment 4: Pharmaceuticals & Related Segments:

The pharmaceutical industry develops, produces, and markets drugs or pharmaceuticals

licensed for use as medications. Pharmaceuticals eliminate the need for inpatient and invasive
care services. They are subject to a variety of laws and regulations regarding the patenting,
testing, and ensuring the safety and efficacy and marketing of drugs. This sector further consists
of many players including Over-the-counter (OTC) drugs & Drug Stores, Prescription drugs,
Biopharmaceutical drugs, Generic drugs, Pharmaceuticals Packing & Labeling Services,
Dietary Fiber Supplement Manufacturing, Vitamin & Supplement Manufacturing, Cough &
Cold Medicine Manufacturing, Health Stores and Eye Glasses & Contact Lens Stores, etc.

Given below are different types of Pharmacy and Medical Stores:

• Over-the-counter (OTC) drugs & Drug Stores

• Prescription drugs
• Biopharmaceutical drugs
• Generic drugs
• Pharmaceuticals Packing & Labeling Services
• Dietary Fiber Supplement Manufacturing
• Vitamin & Supplement Manufacturing
• Cough & Cold Medicine Manufacturing
• Health Stores
• Eye Glasses & Contact Lens Stores

2.3 ELECTRONIC MEDICAL RECORDS

An electronic medical record (EMR) is a digital version of all the information you’d typically
find in a provider’s paper chart: medical history, diagnoses, medications, immunization dates,
allergies, lab results and doctor’s notes. EMRs are online medical records of the standard
medical and clinical data from one provider’s office, mostly used by providers for diagnosis
and treatment. Comprehensive and accurate documentation of a patient’s medical history,
tests, diagnosis and treatment in EMRs ensures appropriate care throughout the provider’s
clinic.
EMRs are more than just a replacement for paper records. They effectively allow
communication and coordination among members of a healthcare team for optimal patient
care.
Its natural evolution began in the 1960s when we began to see “problem-oriented” medical
records (like we understand them today) instead of just the diagnosis and treatment a doctor
provided. This was the first time that third party facilities were able to independently verify
the diagnosis.
“With the internet, change became far more visible, and the internet became an
essential tool for recording and transferring medical records.”
With the dawn of the computer era, many of the earliest computer applications were in use
at hospitals but few other places. Computers gained traction in smaller facilities and clinics
at the same time computers were gaining traction with the general public. With the internet,
change became far more visible, and the internet became an essential tool for recording and
transferring medical records.
As a part of the American Recovery and Reinvestment Act, all public and private healthcare
providers were required to demonstrate “meaningful use” of EMRs by January 1, 2014.
“Meaningful use”, as defined by HealthIT.gov, would achieve the following:
• Improve quality, safety, efficiency, and reduces health disparities
• Engage patients and families
• Improve care coordination and public health
• Maintain privacy and security of patient health information
You can learn more about meaningful use in our What is Meaningful Use article.
Although patient medical records are more comprehensive and accessible than ever before,
refinements and system upgrades are continually enhancing clinic workflow and doctor-
patient interactions.
What is the Difference Between an EMR and an EHR?
While an EMR contains comprehensive information and records of the patient’s history with
one provider, an electronic health record (EHR) contains all of this and it is sharable amongst
authorized providers, health organizations and clinics. An EHR goes beyond the information
from just one provider and includes a comprehensive patient history which can be shared
amongst all providers to help coordinate care for the patient. EMR and EHR systems are both
beneficial tools for clinics – below are some of the key differences between EMR and EHR
systems.

EMRs EHRs
 A digital version of a patient chart A digital record of all patient health
information

Patient record does not easily Allows a patient’s medical information to

travel outside the practice and move with them to other health care
might need to be printed providers and specialists

Mainly used by a provider for Accessed by any number of providers for

diagnosis, treatment and care decision making, diagnosis and care
beyond one provider’s office

Both are necessary on the continuum of care for a patient. The EMR provides a
comprehensive record of care within a practice and the EHR makes that care accessible to a
variety of healthcare providers, even hospitals, if and when needed.
The Advantages of an EMR
Benefits of EMRs for PATIENTS:
• Fewer errors on medical records
• Quicker assessment and care from medical professionals
• Data and results are tracked over time
• Improved health diagnosis, treatment and overall quality of care
• Identify patients who are due for preventive visits and screenings
• Enhanced privacy and security of patient data
• Reduction in patient errors and improved patient care
• Enable evidence-based decisions at point of care
• Follow-up information after a visit such as self-care instructions, reminders for
other follow-up care, and links to web resources
• Access to patient’s own records to view medications and keep up with lifestyle
changes that have improved their health

Benefits of EMRs for CLINICS:

• Save space by eliminating paper records needing to be stored, managed and
retrieved
• Optimize workflow and increased number of patients served per day
• Reduce administrative difficulties and operational costs
• Interface easily with hospitals, pharmacies, labs and state health systems
 • Customizable and scalable electronic records
• Gather and analyze patient data that enables outreach to discreet populations
• Provide clinical alerts and reminders
• Improve documentation and coding
• Enhance research and monitoring for improvements in clinical quality
• Provide built-in safeguards against prescribing treatments that would result in
adverse events
• Track electronic messages to staff, other clinicians, hospitals, labs, etc.
• Links to public health systems such as registries and communicable disease
databases
EMRs don’t just contain information they “compute” it by beneficially manipulating the
information.
For example:
• The EMR automatically checks for problems whenever a new medication is
prescribed to a patient and alerts potential conflicts with the patient’s other
medications or health conditions.
• EMRs can help providers quickly and systematically identify and correct
operational problems. In a paper-based setting, identifying such problems is
much more difficult, and correcting them can take years.
Beyond the improved systems and quality of care for patients, there are also financial
advantages to EMRs. A clinic’s operational costs and overtime labor expenses are reduced
due to the overall efficiency of workflow. Additionally, the ability to more accurately and
efficiently process patient billing improves the clinic’s bottom line.
Any disadvantages of electronic medical records are not necessarily in the system itself, but
in the initial (and natural) challenges of investment, preparation and training in the system.

2.4 CLINICAL DECISION SUPPORT SYSTEM (CDSS)

An average adult makes about 35,000 decisions daily. The majority of them are trivial choices
about clothing, food, or other things that — no offense! — don’t really matter. But everything
changes as we enter the healthcare field where the right decisions save lives while the wrong
ones lead to grave consequences.
To pinpoint the best solution for a particular patient or case, health workers have to sift through
numerous details and factors — and do it fast, under a great deal of pressure. Luckily, the most
routine part of this job can be done by computers — or, to be more specific, by clinical decision
support systems. This article explores how these technologies can improve the speed and
quality of medical decisions.

CDSS basics: types, tasks, and structure

Broadly speaking, a clinical decision support system (CDSS) is a program module that helps
medical professionals make decisions at the point of care. The concept is not new to the
healthcare sector: The first CDSS called MYCIN was built in the early 1970s at Stanford
University. It employed an artificial intelligence model applying over 600 rules to identify
infectious diseases and recommend a course of treatment.
Though MYCIN outperformed medical staff in evaluation accuracy, it was never put in
practice — partially, because of slow performance, but mainly due to the ethical and legal
issues. The very idea of the computer acting as a medical expert was too ahead of its time to
be accepted.

MYCIN expert system interface.

Now, hospitals use CDSSs for numerous tasks, from generating alerts to drug control to
ordering tests. Decision support solutions come in a number of versions. They can be either
standalone tools or integrated parts of larger infrastructures — such as an Electronic Health
Record (EHR) or a Computerized Provider Order Entry (CPOE) system, designed to replace a
paper-based ordering process. Some of them focus on a single problem and perform simple
functions — like sending reminders. Others cover a wide range of processes and include
multiple modules.
No matter the size, modern systems benefit from powerful computing engines, cloud
technologies, and advanced algorithms. But at the architectural level, they haven’t changed
much over the last decades, preserving structures similar to early expert solutions.
CDSS architecture
A typical CDSS contains three core elements: a base or data management layer, inference
engine or processing layer, and user interface.
 Fig 2 Core modules of a typical clinical decision support system.
A data management layer combines

• a clinical database storing information on diseases, diagnoses, and lab findings;

• patient data; and
• a knowledge base in the form of if-then rules or machine learning models.
An inference engine or processing layer applies rules or algorithms and datasets from the
knowledge base to available patient data. The results are displayed via a user interface
layer — a mobile, web or desktop application, an EHR system dashboard or mobile text alerts.
Preserving the same structure, under the hood CDSSs vary in ways they come to a conclusion,
falling into two types — knowledge-based and nonknowledge-based systems.
KNOWLEDGE-BASED CDSS
Systems of this type are built on top of a knowledge base in which every piece of data is
structured in the form of if-then rules. For instance, if a new order for a blood test is placed and
if the same blood test was made within the past 24 hours, then a duplication is possible.
The inference engine runs the built-in logic to combine the evidence-based rules with the
patient’s medical history and data on his or her current condition. The results come in the form
of alerts, reminders, diagnostic suggestions, a series of treatment options or ranked lists of
possible solutions while the final word rests with a human expert.

NONKNOWLEDGE-BASED CDSS
The core difference from the previous group consists of applying machine learning models.
Rather than consulting with a library of predefined if-then rules, such a system learns from past
experiences and finds patterns in historical data. These are the two techniques most widely
used in such CDSSs:

• genetic algorithms (GA) reflecting the mechanics of natural selection described by

Charles Darwin. Just as species change from generation to generation to better fit their
environment, GAs adapt to a new task, producing a number of random solutions and
then iteratively evaluating and improving them until the most fitting option is found.
• artificial neural networks (ANN) that mimic human thinking. Similar to human
brains, ANNs have a set of “neurons” called “neurods.” They are linked to each other
with weighted connections that act as nerve synapses transmitting signals across the
neural network.
Nonknowledge-based systems come with a promise to significantly cut healthcare costs and
relieve the pressure on medical experts. However, there are issues preventing their large-scale
adoption. They include a compute-intensive and time-consuming training process and the
requirement of large datasets needed to improve accuracy of models. But the main obstacle is
the lack of interpretability as systems can’t explain the reasoning behind generated decisions.
Due to drawbacks mentioned, modern CDSSs are primarily knowledge-based. Now, let’s see
what decisions they are able to support.

CDSS MAJOR AREAS OF APPLICATION

Human brains are prone to error — especially, when dealing with large volumes of information
in a high-stress hospital environment. Computerized systems can take a laboring oar of sifting
through tons of data and making countless comparisons to narrow down the number of possible
decisions — from hundreds and thousands to just a few .
Drug selection
Statistics show that 7,000 to 9,000 US patients die annually because of medication errors.
Besides that, a lot more people suffer from complications caused by inappropriate medicines,
ill-judged dosage, or drug incompatibility, increasing treatment costs by over 40 billion a year.
The good news is that nearly 50 percent of medication errors happen at the first — ordering or
prescribing – stage. So, mistakes can be spotted and prevented before they cause any harm.
And that’s where a decision support tool comes in handy, eliminating risks from human factors
like distraction that accounts for around 75 percent of medication errors.
Using critical patient data such as weight, age, allergy status, and current prescriptions, CDSSs
may automatically deal with the following tasks.
Drug allergy checking. The system matches an ordered medication against a patient’s list of
documented allergies, evaluates the probability of unwanted reactions, and generates alerts.
Basic guidance on dosage. Dosing errors account for over 60 percent of all the prescribing
mistakes. But this can be improved by a corresponding decision support module. In the simplest
scenario, the software component generates a patient-specific list of recommended dosing
parameters for a particular medication. It saves a clinician time on selection of the most
appropriate dosage and frequency. The CDSS may as well alert experts to exceeding dosing
limits.
Checking for duplicate therapy. A duplicate therapy occurs when two or more drugs with
the same active ingredient are prescribed simultaneously. It leads to overdose and related
adverse effects. The CDSS feature addressing this problem compares a newly added drug with
active ingredients of drugs in a patient’s profile. If a match is detected, the system generates an
alert.
Drug interactions checking. A drug’s interaction with other substances may change its
expected effect. Based on clinical documentation at hand, a CDSS considers interactions of a
newly prescribed medication with

• other drugs in a patient’s list (drug-drug interactions or DDI),

• food and beverage (drug-food interactions),
• herbals,
• ethanol,
• testing (if the medication can affect the results of laboratory tests),
• pregnancy and lactation, and
• a patient’s disease that can also affect the drug’s performance (drug-disease
interactions).
Today, many Computer Provider Order Entry (CPOE) systems come equipped with drug safety
components that perform duplicate therapy, DDI and drug-dose checking. But you may find
separate decision support modules to complete existing software as well. The example of a
single-task solution is a drug allergy checker by PEPID which can be integrated with any EHR
or other healthcare information system.
Diagnostic support
CDSSs for disease identification are called diagnostic decision support systems (DDSSs) or
medical diagnosis systems (MDSs). They compare information on a patient’s condition with a
knowledge base and generate a list of possible diagnoses.
A specific example of a DDSS is a solution utilizing deep learning for diagnostic imaging. It
would traditionally focus on a specific problem area — say, lung abnormalities or a particular
type of cancer. Similar to other CDS tools, AI-fueled programs work as a second pair of eyes
and make suggestions and alerts — rather than come to a final conclusion.
Cost containment
Integrated in a CPOE system, decision support tools may decrease treatment costs by
suggesting cheaper drug alternatives or spotting test duplications. Studies revealed that CDSSs
save hospital units hundreds of thousands of dollars per year by alerting to cases of excessive
medical testing.
Clinical management
Some clinics employ decision support software to enhance adherence to clinical guidance.
Similar to information about drugs and diseases, hospital rules can be encoded into a
knowledge-based CDSS in the form of IF-THEN-ELSE pieces of information. Such solutions
perform various tasks, from prompting nurses to take specific measurements according to a
protocol to informing doctors about patients who don’t follow their treatment plans.
AUC for Medicare patients
AUC stands for appropriate use criteria that specify when exactly it makes sense to perform a
certain medical service. Starting in January 2020, the Protecting Access to Medicare Act
(PAMA) obliges American hospitals to comply with Medicare’s AUC program for advanced
imaging like computer tomography (CT) or magnetic resonance imaging (MRI).
It means that prior to ordering an expensive test for a Medicare patient, a physician must consult
a clinical decision support mechanism. Without a verdict made by a CDS tool (“appropriate,”
“may be appropriate,” or “rarely appropriate,”), service providers won’t receive reimbursement
for their procedures.