Biomedical subjects
C Safran
Publications and source records attributed to C Safran.
Maintaining the confidentiality of medical records shared over the Internet and the World Wide Web.
The Boston Electronic Medical Record Collaborative is working to develop a system that will use the World Wide Web to transfer computer-based patient information to clinicians in emergency departments. Maintaining adequate confidentiality of these records while still facilitating patient care is paramount to this effort. This paper describes an explicit protocol that would make it possible to electronically identify patients and providers, secure permission for release of records, and track information that is transmitted. It is hoped that other, similar efforts now underway will be able to use and build on this model. Comment on this proposal is invited from all parties with an interest in confidentiality. The system will be used only with "scrubbed" data-data from which all identifiers have been removed-until it is generally agreed that the confidentiality methods proposed here are appropriate and sufficient.
Virtual consolidation of Boston's Beth Israel and New England Deaconess Hospitals via the World Wide Web.
With the advent of Integrated Healthcare Delivery Systems, medical records are increasingly distributed across multiple institutions. Timely access to these medical records is a critical need for healthcare providers. The CareWeb project provides an architecture for World Wide Web-based retrieval of electronic medical records from heterogeneous data sources. Using Health Level 7 (HL7), web technologies and readily available software components, we consolidated the electronic records of Boston's Beth Israel and Deaconess Hospitals. We report on the creation of CareWeb (freya.bidmc.harvard.edu/careweb.htm) and propose it as a means to electronically link Integrated Health Care Delivery Systems and geographically distant information resources.
HOLON: a Web-based framework for fostering guideline applications.
HOLON is a research and development effort in extending middleware in the healthcare field to support application development, in general, and guideline applications, in particular. This framework makes use of open standards for architecture, software, guideline KBs, clinical repository models, information encodings, and intelligent system modules and agents. By pursuing the use of such standards in our middleware components, we hope eventually to maximize reusability of the HOLON framework by others who also adhere to these open standards. This research reflects lessons learned about the extensions needed in these standards if healthcare middleware frameworks are to transparently support application developers and their users over the web.
Telematics in the neonatal ICU and beyond: improving care for high-risk newborns and their families.
The Beth Israel-Deaconess has recently been awarded one of 19 contracts from the National Library of Medicine (NLM) to develop, implement and test a telemedicine application to support the care of Very Low Birth Weight Infants. This project is the only one to focus on the care of newborns. We believe that this project will provide a new national approach to managing the care of high-risk newborns by leveraging evolving communication technology.
Effect of physician gender on the prescription of estrogen replacement therapy.
OBJECTIVE: To determine if women cared for by female physicians are more likely to receive postmenopausal estrogen replacement therapy than women cared for by male physicians. DESIGN: Case-control study with follow-up telephone survey. SETTING: An outpatient practice at an urban teaching hospital in Boston, Massachusetts. PARTICIPANTS: Subjects were women begun on estrogen replacement therapy during an 18-month period; controls were matched on age and month of visit. Seventy-one cases (mean age 60 years, 41% nonwhite) and 142 controls (mean age 60 years, 48% nonwhite) were identified. Fifty-two (82%) of 64 eligible case patients and 89 (80%) of 111 eligible control patients completed a follow-up telephone interview assessing their preferences for female physicians and interest in estrogen replacement therapy. MAIN RESULTS: After adjusting for potential confounders using conditional logistic regression, patients with female physicians were more likely to begin estrogen replacement therapy than those seen by male physicians (odds ratio [OR] 5.4; 95% confidence interval [CI] 1.8, 15.3). Case patients selected their primary care physician more often than control patients and were more interested in estrogen replacement therapy. After adjusting for potential confounders including patients' preferences to select their physician and their interest in estrogen replacement therapy, patients with female physicians were still more likely to begin estrogen replacement therapy than those seen by male physicians (OR 11.4, 95% CI 1.1, 113.6). CONCLUSIONS: We conclude that female patients are more likely to be prescribed estrogen replacement therapy if they are cared for by female physicians rather than male physicians even after accounting for patient preferences. Further research is required to determine whether these differences reflect differences in physicians' knowledge or attitudes regarding estrogen replacement therapy or reflect gender differences in how physicians discuss estrogen replacement therapy with their patients.
Sharing electronic medical records across multiple heterogeneous and competing institutions.
Most early reports of implemented World-Wide Web (W3) medical record systems describe single institution architectures. We describe W3-EMRS, a multi-institutional architecture, and its implementation. Thorny problems in data sharing underlined by the W3-EMRS project are reviewed.
Using HL7 and the World Wide Web for unifying patient data from remote databases.
W3-EMRS is an architecture designed to access clinical data from remote heterogeneous electronic medical record system (EMRS) databases. We describe the technologies used in an experimental implementation of W3-EMRS that concurrently collects data from several sources and presents them in an integrated set of views. After describing some of the organizational constraints, the architectural decision, implementation methodology, and operation of the completed project are discussed.
Guidelines for management of HIV infection with computer-based patient's record.
Computers are steadily being incorporated in clinical practice. We conducted a nonrandomised, controlled, prospective trial of electronic messages designed to enhance adherence to clinical practice guidelines. We studied 126 physicians and nurse practitioners who used electronic medical records when caring for 349 patients with HIV infection in a primary care practice. We analysed the response times of clinicians to the situations that triggered alerts and reminders, the number of ambulatory visits, and hospitalisation. The median response times to 303 alerts in the intervention group and 388 alerts in the control group were 11 and 52 days (p < 0.0001), respectively. The median response time to 432 reminders in the intervention group was 114 days and that for 360 reminders in the control group was over 500 days (p < 0.0001). There was no effect on visits to the primary care practice. There was, however, a significant increase in the rate of visits outside the primary care practice (p = 0.02), which is explained by the increased frequency of visits to ophthalmologists. There were no differences in admission rates (p = 0.47), in admissions for pneumocystosis (p = 0.09), in visits to the emergency ward (p = 0.24), or in survival (p = 0.19). We conclude that the electronic medical record was effective in helping clinicians adhere to practice guidelines.
The health care professional multimedia workstation: development and integration issues.
Workstations for health care professionals provide access to distributed healthcare information systems. They are complex systems that have to manage, in a unified framework, the distributed and multimedia information needed for optimal patient care. The objective is to provide the end-user with a virtual and unified device that conceals the complexity of the underlying information system. Integration and reuse of modular software components are important in the development of such a workstation. A reference set of evaluation criteria is proposed that includes functional, technical, organizational, medical, cultural and ethical, economic and industrial components.
Exploration and exploitation of clinical databases.
Clinical data repositories represent a potential gold mine of information and knowledge. Rapid access to such information can help bridge the gap between clinical care and research, support clinical and executive decision making, and improve the quality of care. A clinical database can be used in four ways: to display information about an individual patient (results reporting); to find data on a patient with similarities to one being seen (case finding); to describe a group of patients with at least one attribute in common (cohort description); and to analyze data patterns in terms of trends or relationships (predictive modeling). It seems unlikely that many important clinical questions will be subject to randomized clinical trials because of the ethics, logistics, and expense that would be involved. Evolving statistical and epidemiological methods allow us to approach these clinical data repositories with the purpose of building predictive models, but a clear understanding of the limitations of routinely collected clinical data and the inherent biases is necessary. The largest barrier to using routinely collected clinical data is not the limitations of the data themselves, but rather the lack of a data paradigm for the decision-maker. We present some of the problems and pitfalls in obtaining and using routinely collected data, based upon the use of ClinQuery at Boston's Beth Israel Hospital and the resources and traditions at the Mayo Clinic.
Predicting in-hospital mortality. The importance of functional status information.
Monitoring risk-adjusted outcomes is the centerpiece of efforts to ensure health care quality. Because data collection is expensive, questions arise concerning what information is essential to adjust for risk. This investigation used retrospective analysis of existing, computerized clinical databases containing laboratory test results, information on chronic coexisting conditions, and nursing evaluations of functional status to predict in-hospital mortality. We studied persons admitted to one tertiary teaching hospital between 1987 and 1992 for cerebrovascular disease or pneumonia. Predictive models for each of the conditions were developed using logistic regression; the results were validated with split samples. We compared the predictive value of the nursing functional status assessments and the clinical laboratory data. For each study condition, the functional status data had as much prognostic information as the laboratory data. Specifically, a nurse's report that a patient required total assistance for bathing was the best single predictor of in-hospital mortality in the models for patients with either cerebrovascular disease or pneumonia. If hospitals admit patients with different levels of functional impairment, it is important to account for these differences before comparing outcomes across facilities. Assessments of functional status are a simple, inexpensive measure that may have considerable value.
Patient entries in the electronic medical record: an interactive interview used in primary care.
We describe the development, implementation, and use of a computer-administered patient interview, the Health History Interview, by over 300 new patients in a primary care practice at Boston's Beth Israel Hospital. The interview has been well accepted by patients and rated positively by providers. It electronically captures clinical information directly from patients for use during their initial encounter with a provider. It facilitates aggregate analysis of clinical data for quality improvement efforts, such as aiming preventive medicine interventions at identified problem areas within the clinic. Expectations management has been an important task throughout the project. Increasing use of the interview beyond the 30-40% of new patients who have taken it will require greater communication with patients, greater convenience to patients and providers, and more evidence of the clinical, administrative, and research benefits of the technique. Most important, full implementation will require fundamental changes in physician practice habits and patterns of communication between patients and the health care system, as well as clearly demonstrated cost-benefit improvements through the use of these tools.
Categorization of free-text problem lists: an effective method of capturing clinical data.
Problem lists assist in organizing patient information in computer based medical records. However, in order to use problem lists for billing, research, decision support and standardization, a categorization of the problems entered is required. We describe the problem list component of our computerized patient record, the On-line Medical Record (OMR), which combines a free-text entry mechanism with a categorization scheme, using a dictionary containing 846 terms. All 118,040 problems entered during the system's six years of use have been analyzed, 477 clinicians have entered a mean +/- S.D. of 238 +/- 604 problems into 22,311 patient records. The average number of problems in each patient's file was 5.1 +/- 3.9. Comments were typed for 80,281 (68%) of the problems, ranging in length from 1 to 2456 characters, with a mean length of 98 +/- 110 characters. Half the problems were entered on the day of the encounter with the patient. Overall, 66% of all problems were categorized in relation to terms from the problem dictionary. Lexical analysis of all problem names showed that 80% could be mapped to Meta 1.4, Snomed 3.0 or a pre-release version of Read 3.0. We conclude that a problem list entry scheme combining free-text entry and optional categorization using a dictionary can result in a high proportion of problems being categorized as desired. Improvement of the system by elimination of unused dictionary terms and addition of 1000 terms identified by the lexical analysis is likely to result in even higher categorization rates.
Patient precautions: a forgotten piece of the electronic patient record.
We define "patient precautions" as a unique group of data that is an essential component of the electronic patient record. Patient precautions include medication allergies, difficult airway precautions, infection control precautions, and advance directives. Any piece of data that is associated with the patient, can affect the management of his or her care, and is relatively static over time (as compared with the patient's medication list and problem list) can be considered a patient precaution. An important property of precautions is that the relevant aspects may be brought to the user's attention at the time a patient care decision must be made. We believe this class of data elements is a unique and important component of the electronic patient record that makes it more valuable than the paper record.
Outcomes research using the electronic patient record: Beth Israel Hospital's experience with anticoagulation.
Using data captured as part of the routine care of outpatients taking the oral anticoagulant warfarin, we described variation in recording reasons for anticoagulation, selecting target International Normalized Ratio (INR) ranges, and performing coagulation blood tests. Laboratory results were directly captured by or entered into an Anticoagulation Flowsheet, a computer program which is fully integrated with our Online Medical Record (OMR). We studied the 177 patients with flowsheets between October 1993 and January 1995. 90% had a reason for anticoagulation entered; 29 different target INR ranges were entered. For patients with a target INR of 2.0-3.0, the mean number of weeks between blood tests, after a test which was in range, was three weeks (standard deviation 1.7 weeks, range one to twelve weeks). We conclude that routinely collected data contained in an electronic patient record (EPR) can be a rich resource for describing and evaluating clinical practice. We also address several limitations to using EPR data: validity of EPR information, lack of coded information, and imperfect capture of clinician thought processes.
Meeting information needs: analysis of clinicians' use of an HIV database through an electronic medical record.
We developed an on-line medical record (OMR) and integrated it into a mature hospital information system. The OMR provides a number of information resources for the care of patients infected with the human immuno-deficiency virus (HIV), including drug information, an on-line version of a newsletter on AIDS, an on-line version of a textbook on HIV, and an index of research protocols that actively enrolls patients. As part of an 18-month clinical trial of this system, we monitored the use of the information resources and whether or not the resources were being used at the time of a patient's visit. During 16% of office visits of HIV-infected patients, clinicians viewed some HIV-related information. Forty-four of 70 clinicians looked at drug information (the most popular resource) 347 times (eight times per person). Two thirds of each clinician's use of the information was through a patient's electronic record, and about half of those (or one third of each clinician's use) were at the time of a patient's visit. Use of other information resources was somewhat less, but the proportion of uses during a patient's visit was similar. Because of this high level of use, we conclude that clinicians need information resources at the point of patient care and that the electronic medical record is an ideal medium through which to convey this information to providers.
A clinical trial of a knowledge-based medical record.
To meet the needs of primary care physicians caring for patients with HIV infection, we developed a knowledge-based medical record to allow the on-line patient record to play an active role in the care process. These programs integrate the on-line patient record, rule-based decision support, and full-text information retrieval into a clinical workstation for the practicing clinician. To determine whether use of a knowledge-based medical record was associated with more rapid and complete adherence to practice guidelines and improved quality of care, we performed a controlled clinical trial among physicians and nurse practitioners caring for 349 patients infected with the human immuno-deficiency virus (HIV); 191 patients were treated by 65 physicians and nurse practitioners assigned to the intervention group, and 158 patients were treated by 61 physicians and nurse practitioners assigned to the control group. During the 18-month study period, the computer generated 303 alerts in the intervention group and 388 in the control group. The median response time of clinicians to these alerts was 11 days in the intervention group and 52 days in the control group (PJJ0.0001, log-rank test). During the study, the computer generated 432 primary care reminders for the intervention group and 360 reminders for the control group. The median response time of clinicians to these alerts was 114 days in the intervention group and more than 500 days in the control group (PJJ0.0001, log-rank test). Of the 191 patients in the intervention group, 67 (35%) had one or more hospitalizations, compared with 70 (44%) of the 158 patients in the control group (PJ=J0.04, Wilcoxon test stratified for initial CD4 count). There was no difference in survival between the intervention and control groups (P = 0.18, log-rank test). We conclude that our clinical workstation significantly changed physicians' behavior in terms of their response to alerts regarding primary care interventions and that these interventions have led to fewer patients with HIV infection being admitted to the hospital.