Lisa B. Done, DVM, MPVM
The information age is definitely here with all of its advantages and frustrations. We are constantly bombarded with information overload and the challenges of information management. Information technology allows us to process information differently, with the primary differences manifest in electronic records and the use of the computer. Information technology also allows us to retrieve information in an entirely different way. Electronic retrieval can be faster and more accurate, but accuracy is dependent upon the construct of the system used for the electronic record and the accuracy of the data.
Hence, the field of medical informatics, a relatively new discipline which intersects information science, medicine, and health care, was born. Medical Informatics is a multi-disciplinary field that includes librarians, computer scientists, educators, and clinicians. It is also the name of an academic discipline developed and pursued over the past decades by a world-wide scientific community engaged in advancing and teaching knowledge about the application of information and communication technologies to healthcare: the place where health, information and computer sciences, psychology, epidemiology, and engineering intersect. Medical Informatics research is diverse including clinical outcomes, quality improvement, genomics (bioinformatics), population biology, public health, and education at all levels.6
In human medicine, health care is monitored and directly affected by quality control systems. These in-place systems allow for an easier implementation of medical informatics. There are two main organizations for human medical informatics: AMIA, the American Medical Informatics Association and IMIA, the International Medical Informatics Association. AMIA states, “Medical informatics has to do with all aspects of understanding and promoting the effective organization, analysis, management, and use of information in health care. While the field of medical informatics shares the general scope of these interests with some other health care specialties and disciplines, medical informatics has developed its own areas of emphasis and approaches that have set it apart from other disciplines and specialties.”1 IMIA’s basic goals and objectives are to (1) promote informatics in health care and research in health, bio, and medical informatics; (2) advance and nurture international cooperation; (3) stimulate research, development, and routine application; (4) move informatics from theory into practice in a full range of health delivery settings from physician’s office to acute and long-term care; (5) further the dissemination and exchange of knowledge, information, and technology; (6) represent the medical and health informatics field with the World Health Organization and other international professional and governmental organizations; (7) move theory into practice by linking academic and research informaticians with caregivers, consultants, vendors, and vendor-based researchers; (8) promote the cross-fertilization of health informatics information and knowledge across professional and geographic boundaries; and (9) serve as the catalyst for ubiquitous worldwide health information infrastructures for patient care and health research.9
AMIA’s bimonthly journal, JAMIA, presents peer-reviewed articles that assist physicians, informaticians, scientists, nurses, and other health care professionals in developing and applying medical informatics to patient care, teaching, research, and health care administration. JAMIA has rapidly established a reputation for presenting high-quality, cutting-edge information. Each issue contains state-of-the-art reviews, discussion forums, and invited editorials presented as brief reviews or full-length papers. A variety of formats accommodate work at all stages, from model formulation through definitive studies.1
The Association for Veterinary Informatics (AVI) was founded by a group of about 20 veterinarians meeting in St. Louis for the 1981 American Veterinary Medical Association (AVMA) Annual Convention.2 Goals of the AVI include serving the membership as an educational resource, promoting the use of information technology and electronic communications in all aspects of the profession, and developing and promoting standards in veterinary information management. The Association has sponsored symposia on computer applications in veterinary medicine at various major veterinary meetings. The Talbot Symposium occurs during the annual AVMA meeting and addresses a wide range of topics including computer technology adaptation in veterinary medical practice.5
Various academic informatics programs exist throughout the country. Stanford School of Medicine includes the Department of Stanford Medical Informatics, which describes the need for its program: “Nowhere is this need more acute than in biomedicine, where scientists and practitioners routinely confront conflicting sources of knowledge and burgeoning numbers of data. Workers in biomedicine urgently require new methods that will enable them to access and apply discipline-specific knowledge to make sense out of clinical and experimental data, to learn from those data, and to advance their underlying disciplines as a result.”11
Various other academic human medical informatics programs exist, but there is only one program in veterinary medical informatics. This interdisciplinary academic, research, and service program, which provides postgraduate training opportunities for veterinarians, is within the Office of Research and Graduate Studies of the Virginia-Maryland Regional College of Veterinary Medicine (VMRCVM). The importance of veterinary medical informatics and the differences from human medical informatics is well described by this group:
“Veterinary medical informatics endeavors to study the structure and properties of medical information and particularly, medical information about animals. To date, most attention has focused on practice management systems which feature appointment scheduling, admission records, pharmacy records, accounting functions, cost-analysis, and cost-control functions. Veterinary informatics experts are also developing programs in areas such as diagnostic decision assistance, expert consultant systems for diagnostic and management assistance, drug information systems, and interactive teaching tools. Events of the recent past have highlighted another role for veterinary medical informatics, namely, to facilitate integration of animal medical data into information systems dedicated to supporting public health and responding to threats of bioterrorism and agriterrorism. Finally, government agencies involved in veterinary medicine depend increasingly on sophisticated electronic documents to receive information from the industries they regulate and to communicate with their constituents and with the public. Much of what can be accomplished in veterinary medical informatics depends on standard means of representing findings and diagnoses, laboratory tests, therapeutic interventions, etc. Unique to veterinary medical informatics is the need to standardize representations of animal anatomy, animal behaviors, and the animals themselves (including the role animals may serve in production systems or as companions). To that end, the VMRCVM veterinary medical informatics program emphasizes the study of medical information standards (SNOMED®, HL7, and LOINC*) Systematized Nomenclature of Medicine (www.snomed.org), Health Level 7 (www.hl7.org), Logical Observation Identifiers Names and Codes (www.regenstrief.org/loinc), and inclusion of veterinary medical content therein.”12
Why is Medical Informatics Important?
Applications of medical informatics range from biomedical data representation and retrieval, health information standards, imaging informatics, health information technology dissemination and evaluation, and telemedicine,4 to very specific applications such as a Veterinary Computerized Anesthetic Record System (VCARS) in testing at the VMTH at UC Davis. The highly successful paper anesthetic record was replicated in the computer application. This shows how alternate form factors can help preserve what is good about the paper-form world while still making available the benefits of real-time data capture.13
SNOMED® (the Systemized Nomenclature of Medicine) was developed in response to the need for standardized data. “SNOMED® recognizes the unique requirements of veterinary medicine, supplying an extensive array of concepts for non-human disorders, anatomic structures, and veterinary procedures. Creation of a non-human subset allows viewing of content exclusive to veterinary medicine while concept definitions place animal disorders, findings, and procedures in a broad-based medical context.”10 SNOMED Clinical Terms (SNOMED CT®), is the universal health care terminology that makes health care knowledge usable and accessible wherever and whenever it is needed.”10
Why are standardized terms even important? In a paper entitled “Word Search Performance for Diagnosis of Equine Surgical Colic in Free-Text Electronic Patient Records,” key word searches for four GI disorders (enterolithiasis, displacement, torsion or volvulus, and adhesions) were done. The sensitivity of these word searches ranged from 33–98%, and it was concluded that if GI disorders were uniformly named search limitations would be minimized. Results suggested that searches of free-text, electronic patient records are susceptible to inaccuracies for a variety of reasons. This study identified one-third of the relevant cases from the medical record database, and on the other hand, for every 100 records the word search retrieved, only two cases were relevant. Reasons for these results were synonymous expression of GI disorders; derivational variation in expression (e.g., enterolith versus enterolithiasis); surgical findings were not reported in the record; misspellings; and inflectional variations in expression including singular versus plural, or past, present, and future tense. Free-text retrieval is based on the assumption that it is a simple matter for searchers to imagine all of the exact words and phrases under which the desired information might be recorded.8
Implementation of veterinary medical informatics on an even broader scope could affect the zoo medicine and wildlife community, especially when working with federal agencies. This is illustrated by the proposed Consolidated Health Informatics (CHI) Initiative: Health Care and Vocabulary Standards for Use in Federal Health Information Technology Systems. The CHI initiative is a collaborative effort to adopt federal-government-wide health information interoperability standards (messaging and vocabulary). These standards will be implemented by federal agencies to allow the federal government to exchange electronic health information.7 Electronic communication and interactions of zoo and wildlife electronic medical systems and records would be better facilitated if we also utilized these messaging and vocabulary standards. Informatics knowledge is the important link which will build the information and messaging standards that, in turn, will tie agencies together. The USDA, in tackling a national animal identification system, is planning to link to a network of private and state-operated animal tracking databases.3,4 The zoo medicine community also has important animal identifier tracking needs.
Medical informatics can involve very detailed research and is a discipline so specialized it requires the mastery of its own specialized terminology. The research can be very esoteric or practical. Research also actively occurs in the various academic venues such as at the Yale College of Medical Informatics which lists the following clinical informatics project as an example: exploring the use of mobile, pen-based devices that incorporate guideline knowledge to provide clinical-decision support and overcoming challenges to user acceptance.14
Research also occurs in areas such as disease management and the internet, decision support, the human-computer interaction and interfaces, the electronic medical record, telemedicine, and standardized medical terminology.
How Does This Affect You?
The information demands of digital imaging will eventually affect all of us in institutions and/or private practice. Important standard image structure and communication protocols will need to be fully incorporated into our systems (DICOM: Digital Imaging and Communications in Medicine®) in order to affect legal standardization of images.
Other effects primarily reflect the need and implementation of standards for a more global approach to important veterinary medical information.
Harmonizing standards is an important issue and not always appreciated by everyone anxious to implement well-designed electronic medical records. Again, this issue is succinctly expressed in a veterinary medical informatics newsletter:
“The great thing about standards is that there are so many to choose from.”
This is a favorite quote used by those working on standards because it seems like an endless battle to keep standards from conflicting with each other. HL7 is the undisputed leader of messaging standards. Standards must work closely together if things are going to work. The best way to ensure that this happens is for the standards development organizations to work together directly. That is what is happening with the Continuity of Care Record standards for transfer of patient information when a patient is referred to a specialist or skilled nursing facility. Are there lessons here for veterinary referral practice informatics?5
Perhaps the biggest challenge for the use and implementation of veterinary medical informatics involves implementation. We must overcome “techno-phobia” and reluctance to change what has always seemed to work for us in the past. These issues will only continue to become more and more important. We have the opportunity to embrace medical informatics and utilize the skill and expertise of groups and individuals well-trained in this new and evolving field to help the zoo and wildlife medicine community advance further into the information age.
1. American Medical Informatics Association. www.amia.org/informatics.
2. Association for Veterinary Informatics. www.avinformatics.org.
3. Association for Veterinary Informatics Newsletter. www.avinformatics.org/newsltr/2005/august05.html. (VIN editor: link was not accessible as of 1/25/2021/.)
4. Association for Veterinary Informatics Newsletter. http://www.avinformatics.org/newslter/2006/janurary06.html. (VIN editor: link was not accessible as of 1/25/2021/.)
5. Association for Veterinary Informatics Newsletter. http://www.avinformatics.org/newslter/2005/november05.html. (VIN editor: link was not accessible as of 1/25/2021/.)
6. College of Medicine, University of Florida, Office of Medical Informatics. www.medinfo.ufl.edu/omi. (VIN editor: link was not accessible as of 1/25/2021/.)
7. Consolidated Health Informatics (CHI) Initiative; Health Care and Vocabulary Standards for Use in Federal Health Information Technology Systems. www.hhs.gov/healthit/chi.html. (VIN editor: link was not accessible as of 1/25/2021/.)
8. Estberg L, Case JT, Walters RF, et al. Word search performance for diagnoses of equine surgical colics in free-text electronic patient records. Prev Vet Med. 1998;34:161–174
9. International Medical Informatics Association. http://www.imia.org/about. (VIN editor: link was not accessible as of 1/25/2021/.)
10. SNOMED® (the Systematized Nomenclature of Medicine). www.snomed.org/clinical/vetmed.html. (VIN editor: link was not accessible as of 1/25/2021/.)
11. Stanford School of Medicine, Stanford Medical Informatics. www.smi.stanford.edu. (VIN editor: link was not accessible as of 1/25/2021/.)
12. Veterinary Medical Informatics at Virginia Tech. informatics.vetmed.vt.edu. (VIN editor: link was not accessible as of 1/25/2021/.)
13. VCARS, the Veterinary Computerized Anesthetic Record System. www.avinformatics.org/newslter/2005/november05.html. (VIN editor: link was not accessible as of 1/25/2021/.)
14. YCMI Research Projects. www.ycmi.med.yale.edu/projects.html. (VIN editor: link was not accessible as of 1/25/2021/.)