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Basic concepts in medical informatics

J C Wyatt and J L Y Liu

J. Epidemiol. Community Health 2002;56;808-812

doi:10.1136/jech.56.11.808

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808

GLOSSARY

Basic concepts in medical informatics

J C Wyatt, J L Y Liu
.............................................................................................................................

J Epidemiol Community Health 2002;56:808–812

This glossary defines terms used in the comparatively • There is general agreement on what the term
young science of medical informatics. It is hoped that it means and how it is used.
will be of interest to both novices and professionals in • There is value in attempting to define the term,
even though there may be debate about it.
the field. We trust this list of terms will be informative
.......................................................................... for novices and encourage discussion among
medical informatics professionals, particularly on
terms for which there is no widespread agree-

M
edical informatics is the study and appli-
cation of methods to improve the man- ment*. For readers who are interested in pursuing
agement of patient data, clinical knowl- the subject further, additional resources are cited
edge, population data, and other information at the end of the list.
relevant to patient care and community health. It
is a young science, which emerged in the decades ALGORITHM
after the invention of the digital computer in the A process for carrying out a complex task broken
1940s. Mechanical computing in medicine had a down into simple decision and action steps. Often
much earlier origin, in the 19th century, with assists the requirements analysis process carried out
Herman Hollerith’s “punched-card data- before programming.
processing system” originally used for the US
census and subsequently developed to support
surveys in public health and epidemiology.1 This BIOINFORMATICS
example reflects the multidisciplinary nature of The use of medical informatics methods to facilitate
medical informatics, which interacts with various research in molecular biology.
fields, including the clinical sciences, the public
health sciences (for example, epidemiology and CHECKLIST
health services research) as well as cognitive, A type of clinical decision tool: a form listing one or
computing, and information sciences. more items of patient data to be collected before,
Given the diversity of backgrounds of medical during or after an encounter; can be paper or
informatics workers, newcomers can easily be computer based.
confused by the jargon used in the field. An intro-
duction to basic concepts would therefore be use-
CLINICAL CODING SYSTEM (CLINICAL
ful to those interested in learning more about
medical informatics. In recent years, various
THESAURUS, CONTROLLED
branches of the discipline have appeared, includ- VOCABULARY)
ing public health informatics, consumer health A limited list of preferred terms from which the
informatics, and clinical informatics. In a debate user can draw one or more to express a concept
on whether medical informatics and these such as patient data, a disease or drug name, etc.
branches are distinct disciplines, Shortliffe and An alphanumeric code corresponding to the term
Ozbolt argued that “informatics is built on a is then stored by the computer. Synonyms or close
re-usable and widely applicable set of methods matches to each preferred term are usually avail-
that are common to all health science disciplines, able and map onto the same internal codes. This
and that ‘medical informatics’ continues to be a approach makes it easier for a computer to
useful name for a composite core discipline that analyse data than the use of free text words or
should be studied by all students, regardless of phrases. Examples of clinical coding systems
their health profession orientation.”2 3 Our defini- include SNOMED-CT (divergent codes used to
tions of the various branches of medical infor- capture patient data), MeSH (terms used to index
matics below reflect this. biomedical literature) and ICD-10 (convergent
One or more of the following criteria were used disease codes for international comparisons, with
to select terms included in this list of concepts: specific rules to guide coders). Clinical coding
• The term is likely to be novel to epidemiologists systems play a key part in epidemiological studies
See end of article for and public health professionals. and health service research, from the use of
authors’ affiliations • An existing word may have a widely accepted MeSH terms to conduct literature searches for
....................... meaning but is used in a specific way in the systematic reviews to studies that use ICD codes
Correspondence to: medical informatics field. to classify and compare diseases. To prevent
Professor J C Wyatt, • The term is relevant to epidemiology and pub- information loss, it is vital that the terms and
Department of Medical
Informatics, Academic
lic health.
Medical Centre, University • It is essential to understanding medical infor- .................................................
of Amsterdam, matics.
Netherlands; * Notes to the list of concepts: Italic means “see also”.
[email protected] • It is enduring—that is, not about some Synonyms are mentioned in parentheses, after the core
....................... transient technology. term.

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Medical informatics 809

codes are never changed or dropped, only added to. Obsolete DATA QUALITY
terms can be marked as such to deter inappropriate use. Con- The degree to which data items are accurate, complete,
tinuing maintenance is needed to incorporate new terms and relevant, timely, sufficiently detailed, appropriately repre-
codes for new concepts and synonyms as they arise. sented (for example, consistently coded using a clinical coding
system), and retain sufficient contextual information to
CLINICAL DATA SYSTEM support decision making.
Any information system concerned with the capture, process-
ing, or communication of patient data.4 DATABASE
A collection of data in machine readable format organised so
CLINICAL DECISION TOOL that it can be retrieved or processed automatically by compu-
Any mechanical, paper, or electronic aid that collects or proc- ter. A flat file database is organised like a card file, with many
esses data from an individual patient to generate output that records (cards) each including one or more fields (data items).
aids clinical decisions during the doctor-patient encounter.5 A relational database is organised as one or more related
Examples include decision support systems, paper or computer tables, each containing columns and rows. Data are organised
reminders and checklists, which are potentially useful tools in in a database according to a schema or data model; some items
public health informatics, as well as other branches of medical are often coded using a clinical coding system.
informatics.
DECISION SUPPORT SYSTEM (COMPUTER DECISION
CLINICAL INFORMATION AID)
Organised patient data or medical knowledge used to make clini- A type of clinical decision tool: a computer system that uses two
cal decisions (adapted from Shortliffe et al6); may also include or more items of patient data to generate case specific or
directory information. Many activities in public health and encounter specific advice.11 Examples include computer risk
epidemiology (for example, surveillance systems, cohort stud- assessors to estimate cardiovascular disease risk12 and the
ies to assess the effects of a risk factor of disease, and clinical Leeds Acute Abdominal Pain system, which aided the diagno-
trials to estimate efficacies of new treatments) entail the sis of conditions causing such pain.13 Evidence adaptive deci-
organisation of such data (for example, case report forms for sion support systems are a type of decision aid with a knowl-
individual patients) into useable information (for example, edge base that is constructed from and continually adapts to
incidence of notifiable cases of disease from surveillance pro- new research based and practice based evidence.14
grammes and summary evidence from cohort studies or clini-
cal trials, expressed as odds ratios for certain harmful and DECISION TREE
beneficial outcomes). See also: information. A way to model a complex decision process as a tree with
branches representing all possible intermediate states or final
CLINICAL INFORMATICS outcomes of an event. The probabilities of each intermediate
The use of medical informatics methods to aid management of state or final outcome and the perceived utilities of each are
patients using an interdisciplinary approach, including the combined to attach expected utilities to each outcome. The
clinical and information sciences.6 science of drawing decision trees and assessing utilities is
called decision analysis.
COMMUNICATION
The exchange of information between agents (human or auto- DEMONSTRATION STUDY
mated) face to face or using paper or electronic media.7 Study that establishes a relation—which may be associational
Requires the use of a shared language and understanding or or causal—between a set of measured variables. In epidemiol-
common ground. ogy, cohort studies, randomised trials, and blind comparisons
of a test with a gold standard are typical demonstration
studies.6 15 See also measurement studies.
COMPUTER VISION (IMAGE INTERPRETATION)
The use of computer techniques to assist in the interpretation
of images, such as mammograms. DIRECTORY INFORMATION
Information specific to an organisation or service that is useful
in managing public health services, health care services, or
CONFIDENTIALITY (PROTECTING PRIVACY) patients. Examples include a phone directory, a lab handbook
The policies restricting access to a person’s data to those whom listing available tests and specimens to use, and a list of drugs
the patient agrees need access to them, except rarely in emer- in the local formulary.
gency and for the public good (for example, to contain
epidemics, allow important research to be undertaken, or
solve serious crime). In addition, other regulatory and institu- eHealth
tional approval may be needed (for example, the need to seek The use of internet technology by the public, health workers,
consent from medical ethics committees or relevant national and others to access health and lifestyle information, services
authorities). In recent years, leading public health researchers and support; it encompasses telemedicine, telecare, etc. For
have warned that legislation enacted to protect patients’ discussion on the scope and security issues of eHealth, see a
medical data in the UK, Europe, and US could potentially recent report by the National HealthKey Collaborative.16
hamper observational research and medical record linkage
studies.8 9 ELECTRONIC HEALTH RECORD (EHR)
In the UK, the lifelong summary of a person’s health episodes,
CONSUMER HEALTH INFORMATICS assembled from summaries of individual electronic patient
The use of medical informatics methods to facilitate the study records and other relevant data.17
and development of paper or electronic systems that support
public access to and use of health and lifestyle information. ELECTRONIC PATIENT RECORD (EPR)
For additional discussion on the scope of consumer health A computer based clinical data system designed to replace paper
informatics, see Eysenbach.10 See also eHealth. patient records.

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810 Wyatt, Liu

EXPLICIT KNOWLEDGE MEASUREMENT STUDY

Knowledge that can be communicated on paper or electroni- Study of the reliability, validity, or ease of use of a
cally, without person to person contact.18 Public health work- measurement instrument or method in a defined
ers and physicians cannot use explicit knowledge if they can- population.15 See also demonstration study.
not access it. There is thus a need to identify, capture, index,
and make available explicit knowledge for professionals, a MEDICAL INFORMATICS (HEALTH INFORMATICS)
process called codification. Much of the work done by the The study and application of methods to improve the
Cochrane Collaboration entails codification of explicit knowl- management of patient data, medical knowledge, population data
edge. See also: tacit knowledge. and other information relevant to patient care and community
health. Unlike some other definitions of medical informatics
GEOGRAPHICAL INFORMATION SYSTEM (GIS) (or example, Greenes and Shortliffe28), this definition puts the
Computer software that captures, stores, processes, and emphasis on information management rather than technol-
displays location as well as other data. The display may ogy. Branches of medical informatics include bioinformatics,
preserve distance ratios between data objects (for example, clinical informatics, consumer health informatics and public health
true scale maps) or link similar objects, ignoring distance (for informatics.
example, topological maps such as that distributed to the
public for the London Underground). GIS software is used in MEDICAL KNOWLEDGE (CLINICAL KNOWLEDGE)
many ecological studies of disease. A famous example is Peto’s Information about diseases, therapies, interpretation of lab
study of diet, mortality, and lifestyle in rural China.19 Disease tests, etc, which is potentially applicable to decisions about
mapping studies have also been conducted to assess childhood multiple patients and public health policies, unlike patient data.
leukaemia in areas with different radon levels,20 the clustering This information should where possible be based on sound
of respiratory cancer cases in areas with a steel foundry,21 and evidence from clinical and epidemiological studies, using valid
socioeconomic gradients in infant mortality.22 GIS are also and reliable methods. See also: explicit knowledge, tacit knowledge,
used for public health planning and surveillance purposes at knowledge management.
local or national health departments. Care should be taken by
policy makers in interpreting maps produced by GIS software,
MINIMUM DATASET
particularly in regard to the ecologic fallacy.23
A list of the names, definitions and sources of data items
needed to support a specific purpose, such as surveillance of
INFORMATION the health of a community, investigation of a research hypoth-
Organised data or knowledge used by human and computer esis or monitoring the quality of care in a registry.
agents to reduce uncertainty, take decisions, and guide actions
(adapted from Shortliffe et al6 and Wyatt24). See also: clinical OBJECTIVISTIC EVALUATION
information, patient data, medical knowledge. An evaluation approach that uses experimental designs and
statistical analyses of quantitative data.6 15 Such an approach is
INFORMATION DESIGN never completely objective. See also subjectivistic study.
The science and practice of designing forms, reports, computer
screens, etc, so that the information they contain can be found ONTOLOGY
rapidly and interpreted without error (adapted from Sless25). A description of the concepts and relations in a domain, such
Information design is based on psychological and graphical as drug prescribing. Sample concepts here would be “patient”,
design theories and empirical studies of human perception “prescriber”, and “drug”; relevant relations might include
and decision making using alternative formats for “prescribes to”, “requests prescription from”, and “causes side
information.25a effects to”. A taxonomy or hierarchy is a simple kind of ontol-
ogy in which concepts are arranged according to only one
KNOWLEDGE BASE relation: “is a kind of ”. Note that ontology as used here has a
A store of knowledge represented explicitly so that a compu- different meaning from its use in the philosophy of science, an
ter can search and reason with it automatically; often uses a area of interest to theoretical epidemiologists.
clinical coding system to label the concepts. See also decision sup-
port system. PATIENT DATA
Information about an individual patient and potentially
KNOWLEDGE BASED SYSTEM (EXPERT SYSTEM) relevant to decisions about her current or future health or ill-
A computer decision support system with an explicit knowledge ness. Patient data should be collected using methods that
base and separate reasoner program that uses this to give minimise systematic and random error. See also: medical
advice or interpret data, often patient data. knowledge, data quality.

PRACTICE INNOVATION (RESEARCH

KNOWLEDGE MANAGEMENT
IMPLEMENTATION, BEHAVIOUR CHANGE)
The identification, mobilisation and use of knowledge to
Applying usually explicit knowledge to innovate in public health
improve decisions and actions. In public health and medicine,
and clinical practice by identifying barriers to change and
much of this work involves the management of medical knowl-
applying appropriate practice innovation methods to overcome
edge (from epidemiological studies, randomised controlled
these (adapted from Wyatt26). See also: knowledge management.
trials, and systematic reviews) so that it is actually used by the
physician. This entails practice innovation26 or narrowing the gap
between what we know and what we do. The NHS is develop- PRACTICE INNOVATION METHODS (RESEARCH
ing a program of knowledge codification to inform routine IMPLEMENTATION, BEHAVIOUR CHANGE
problem solving, for example, through the National Electronic METHODS)
Library of Health, guidelines from the National Institute of A range of methods that can potentially overcome barriers to
Clinical Excellence (NICE), and care pathways and triage change in the practice innovation process, such as clinical audit,
algorithms used in the NHS Direct Clinical Advice System.27 outreach visits or clinical decision tools.

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Medical informatics 811

PUBLIC HEALTH INFORMATICS than be prescribed in advance. As we can never truly

The use of medical informatics methods to promote public health understand another person’s feelings, such studies always
practice, research, and learning, using an interdisciplinary approximate the subjective. See also objectivistic study.
approach, including the public health sciences, for example,
epidemiology and health services research, and the information TACIT KNOWLEDGE (INTUITION)
sciences, for example, computing science and technology Knowledge that requires person to person contact to transfer
(adapted from Yasnoff et al29). In a recent paper outlining an and cannot be communicated on paper or electronically.18 27
agenda for developing this branch of informatics, Yasnoff et al30 Over time, some tacit knowledge can be analysed, decom-
argued for the need to construct, implement, and integrate posed, and made explicit. See also: explicit knowledge.
public health surveillance systems at national and local levels, to
enable rapid identification and response to disease hotspots TELECARE
(and more topically, bioterrorism). As Yasnoff rightly points out, A kind of telemedicine with the patient located in the commu-
methods of assessing costs and benefits of such systems are nity (for example, their own home); see also eHealth.
needed. Public health informatics can also contribute in other
areas, for example, reminders have played an important part in TELEMEDICINE
prevention programmes such as smoking cessation advice to The use of any electronic medium to mediate or augment
smokers31 and the use of preventive care for patients.32 clinical consultations. Telemedicine can be simultaneous (for
example, telephone, videoconference) or store and forward
REGISTRY (for example, an email with an attached image). See also
A database and associated applications that collects a minimum eHealth.
dataset on a specified group of patients (often those with a cer-
tain disease or who have undergone a specific procedure), Additional resources
health professionals, organisations, or even clinical trials. Reg- Readers who are interested in general coverage of the field of
istries can be used to explore and improve the quality of care medical informatics are encouraged to refer to standard
or to support research, for example to monitor long term out- texts.15 35 36 Those who are interested in alternative or comple-
comes or rare complications of procedures. Key issues in reg- mentary definitions of the above terms can look up various
istries are maintaining confidentiality, coverage of the target sources.6 7 37–39
population, and data quality.
ACKNOWLEDGEMENT
REMINDER We thank Ameen Abu Hanna (Department of Medical Informatics,
University of Amsterdam) and the JECH anonymous referees, who all
A type of clinical decision tool that reminds a doctor about some
provided useful comments on drafts.
item of patient data or clinical knowledge relevant to an individual
patient that they would be expected to know. Can be paper
.....................
based or computer based; includes checklists, sticky labels on
Authors’ affiliations
front of notes, an extract from a guideline placed inside notes,
J C Wyatt, Department of Medical Informatics, Academic Medical
or computer based alerts. There has been much interest in Centre, University of Amsterdam, Netherlands
reminders as a practice innovation method recently because of the J LY Liu, Centre for Statistics in Medicine, Institute of Health Sciences,
poor uptake of practice guidelines, even those based on good Oxford University, UK
quality evidence. An example is the treatment of dyslipidae- Funding: the NHS R&D Health Technology Assessment Board funded part
mia in primary care, where there is a big gap between recom- of this work.
mendations and actual practice.33
Conflicts of interest: none.

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