1.

Clinical Decision Support System

Clinical diagnosis, is a mapping from a patients data (normal and abnormal history, physical
examination, and laboratory data) to a database of disease states.
Diagnosis is defined as the process of determining by examination the nature and circumstances
of a diseased condition,
A DDSS- Diagnostic Decision Support System can be defined as: a computer-based
algorithm that assists a clinician with one or more component steps of the diagnostic
process

Limitations of CDSS and DDSS

1.Clinical decision support systems have been promoted as one of the key features of
electronic health records most likely to lead to a real transformation in our healthcare
system. However, is that often these systems are underutilized. Decision support
features are often not used and clinicians frequently ignore, override, or fail to seek
out suggestions that could improve care.

2. This underutilization may be even more true for diagnostic decision support
systems (DDSS), which were some of the earliest examples of medical informatics
innovations.

There have been a variety of DDSS that focus on specific problem areas, some of which
utilize artificial intelligence approaches and others use statistical pattern recognition
models
3. Genomic bioinformatics
What is it?

Usage of Genomic Bioinformatics

Existing CDS- Clinical decision support technologies already play a role in supporting
genetic testing and data access processes

The development and availability of genomic applications for use in clinical care is
accelerating rapidly. The routine use of genomic information, however, is beyond most health-
care providers formal training, and the challenges of understanding and interpreting genomic
data are increased by the demands of clinical practice. nearly all physicians, for example, agree
that genetic variations may influence drug response, but only a small fraction feel adequately
informed about pharmacogenomic testing.

Clinical decision support (CDS) embedded into clinical information systems, such as the
electronic health record (EHR) and the personal health record (PHR), is recognized as being
necessary to facilitate the appropriate use of genomic applications.

Why is CDS needed to facilitate genomic applications?

CDS provides - clinical knowledge and patient-specific information, filtered or

presented at particular times to enhance clinical care by incorporating the preferences of
health-care consumers.
 EHRs and PHRs theoretically may support access to and storage of genetic
data. These systems may also support data exchange between repositories and
enable CDS embedment and linkage. .

As informed to us by Dr Gagan Arora, Senior Consultant , Oncology, Fortis Hospital, Noida,

Phases of genetic testing and previous efforts to conceptualize the process of genetic
testing

Three phases of genetic testing, including the preanalytic, analytic, and postanalytic phases, are
defined according to the US Centers for Disease Control and Prevention Notice of Intent
published in the Federal Register, Vol. 65, No. 87, 5/4/2000 25928.

The preanalytic phase involves determining when and what genetic tests are appropriate to
answer a clinical question.

The analytic phase involves steps to perform interrogative analyses of genetic material.

The postanalytic phase involves reporting and interpreting genetic test results.

This diagram can be drawn for genetic informatics

4. Predictive diagnosis -
Progressive increase of mean age and life leads to chronic degenerative diseases (CDD) such as cancer,
cardiovascular, autoimmune or neurodegenerative diseases among the elderly.
CDD are of complex diagnosis, difficult to treat and very expensive.
However, recent development in modern medicine especially in genetics, proteomics, and informatics is
leading to the discovery of biomarkers associated with different CDD that can be used as indicator of
disease's risk in healthy subjects.
Therefore, predictive medicine is merging and medical doctors may use markers to identify persons with
high risk of developing a given CDD before the clinical manifestation of the diseases. This innovative
approach may offer substantial advantages, since the promise of personalized medicine is to preserve
individual health in people with high risk by starting early treatment or prevention protocols.
However the road to an effective personalized medicine is still long, several (diagnostic) predictive
instruments for different CDD are under development, some ethical issues have to be solved.
Operative proposals for the health care systems are now needed to verify potential benefits of predictive
medicine in the clinical practice. In fact, predictive diagnostics, personalized medicine and personalized
therapy have the potential of changing classical approaches of modern medicine to CDD.

5. What is EHR and what does it include?

An electronic health record (EHR) contains patient health information,
such as:

Administrative and billing data

Patient demographics
Progress notes
Vital signs
Medical histories
Diagnoses
Medications
Immunization dates
Allergies
Radiology images
Lab and test results
An EHR is more than just a computerized version of a paper chart in a
providers office. Its a digital record that can provide comprehensive
health information about your patients. EHR systems are built to share
information with other health care providers and organizations such as
laboratories, specialists, medical imaging facilities, pharmacies,
emergency facilities, and school and workplace clinics so they contain
information from all clinicians involved in a patients care.

6.
The Interoperable eHealth system in Europe - was it handled correctly or not ?

All there on page 4 in case study

First say what it is and then what can go wrong and then ways to prevent from going wrong.
 WHAT IT IS?
Interoperable eHealth system in Europe*. The information in each record will include
demographic data, hospital visits, past illnesses, allergies, scans,X-rays and much more. There
are obvious potential advantages for the individual, for researchers and also for health care
planners, but there are some implications that need to be considered as well.
WHAT CAN GO WRONG?
Apart from the different languages and health practices across the European Union,
there are also hardware and software compatibilities that have to be considered.
Implementing such a system is extremely expensive and complex, as has been
shown in the UK; attempts in some other countries have allegedly led to clinical
mistakes. The attitudes of patients and the impact on medical staff need to be
considered. On the other hand, those involved in bioinformatics, are particularly
interested in the vast amount of data that could be used for predictive diagnosis
and the possibility of including DNA in the records could lead to advances in
genomic bioinformatics.

Ways to prevent the scenario from going wrong or provide further detail on what else could
have been done.
Talk a bit abt developments in all three :
bioinformatics
predictive diagnosis and
genomic bioinformatics.

6. Explain how the computer system for the new clinic, Tall Trees can be very effective.
The clinic intends to include telemedicine in its services, in order to offer health care to
all. They must employ The Internet of Health Things..
An addition to telemedicine is the rapid development of the internet of health things,
which can be incorporated into telemedicine. It can also be used by people wishing to
monitor their own health, thanks to the use of wearables and the incorporation of near
field communication (NFC) and radio-frequency identification (RFID) into many mobile
devices. This allows medical data to be relayed continually to a health centre.

The Internet of Things (IoT) is a computing paradigm which is quickly becoming the
dominant reality of our interconnected world. The paradigm of IoT proposes that
everyday objects would be capable of both disseminating information to a network and
responding to information from the networkincreasingly independent of human
intervention. IoT is permeating all industries and, accompanied with the broad technology
trends of social media, mobility, analytics and cloud computing, is supporting the digital
transformation of industries. In the context of health, IoT is enabling new business
paradigms, such as interacting with patients through wearable or embedded devices.
Moreover, IoT is enabling the digital transformation of a hospital. Acute care institutions
are already the most complex buildings that people use. Hospitals are populated with
 thousands of systemsbuilding systems, medical equipment, clinical and administrative
systems and now increasingly patients with wireless or embedded devices. These systems
have traditionally been standalone, but a distributed network of smart healthcare devices,
machines and systems is now able to be connected into an orchestrated Internet of Health
Things (IoHT). CGI has created an IoHT framework to assist healthcare provider
organizations in structuring their IoHT solutions to achieve targeted outcomes and scale
to a comprehensive vision. By 2020, 50 billion things will be connected to the Internet.
Benefits of IoHT The digital transformation of the health industry offers comprehensive
improvements in patient engagement, productivity, and risk mitigation, as well as new
revenue and operating paradigms. Health enterprises are seeking to improve their ability
to be aware of the situations in their surroundings and to patients. Having situational
awareness requires knowing the location and the status of people (staff, patients, etc.) and
resources (medical equipment, devices, supplies, etc.) at any time within the context of
patient care. Situational intelligence is taking action on that awareness to improve the
delivery of care or operations that support care

7.
Challenges faced IN THE CASE STUDY ARE BELOW:

Doctor Metaxis and his clients must focus on the following challenges:
1.The feasibility and consequences of developing a coherent EHR system;
2.The effect of technological developments on health careers;
3.Development and implication of bioinformatics for predictive diagnosis;
4.Combining electronic and human resources in order to get health services to
those in remote or
underdeveloped areas.

Examples or countermeasures in the Challenges Faced development and

implication of bioinformatics for predictive diagnosis.

The challenge faced in the development of bioinformatics is mainly in

integrating molecular and clinical data to accelerate the translation of
knowledge discovery into effective treatment and personalized medicine.

CBI(Clinical Bioinformatics) shares methods and goals with Translational

Bioinformatics (TBI), which has been defined as the "development of
storage, analytic, and interpretative methods to optimize the
transformation of increasingly voluminous biomedical data - genomic data
in particular - into proactive, predictive, preventive, and participatory
health management

Countermeasures:
Looking at CBI clinical bio informatics from the technological side,
experts have identified three areas that need advancement and further
research.
These include: 1) the development of data warehouses and ICT
infrastructures for data sharing,
2) the definition of standards for sharing phenotypic data
and

3) the implementation of new tools to implement efficient

search computing solutions.

Example:
1)i2b2 (Informatics for Integrating Biology and the Bedside) is an NIH-
funded National Center for Biomedical Computing based at Partners
HealthCare System that is an integrated framework for using clinical data
for research

In the system mentioned above,

A very large central fact table (observation_fact) is surrounded by and
connected to the smaller dimension tables, i.e., the patient, observer, visit,
concept and modifier dimensions (In figure below).
A fact is defined as an observation on a patient, made at a specific time, by
a specific observer, during a specific event.
Dimension tables hold descriptive information and attributes about the
facts.