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Harold P Lehmann

Publications and source records attributed to Harold P Lehmann.

15 recordsLinked to original sources
PubMed2005

Information resource preferences by general pediatricians in office settings: a qualitative study.

BACKGROUND: Information needs and resource preferences of office-based general pediatricians have not been well characterized. METHODS: Data collected from a sample of twenty office-based urban/suburban general pediatricians consisted of: (a) a demographic survey about participants' practice and computer use, (b) semi-structured interviews on their use of different types of information resources and (c) semi-structured interviews on perceptions of information needs and resource preferences in response to clinical vignettes representing cases in Genetics and Infectious Diseases. Content analysis of interviews provided participants' perceived use of resources and their perceived questions and preferred resources in response to vignettes. RESULTS: Participants' average time in practice was 15.4 years (2-28 years). All had in-office online access. Participants identified specialist/generalist colleagues, general/specialty pediatric texts, drug formularies, federal government/professional organization Websites and medical portals (when available) as preferred information sources. They did not identify decision-making texts, evidence-based reviews, journal abstracts, medical librarians or consumer health information for routine office use.In response to clinical vignettes in Genetics and Infectious Diseases, participants identified Question Types about patient-specific (diagnosis, history and findings) and general medical (diagnostic, therapeutic and referral guidelines) information. They identified specialists and specialty textbooks, history and physical examination, colleagues and general pediatric textbooks, and federal and professional organizational Websites as information sources. Participants with access to portals identified them as information resources in lieu of texts. For Genetics vignettes, participants identified questions about prenatal history, disease etiology and treatment guidelines. For Genetics vignettes, they identified patient history, specialists, general pediatric texts, Web search engines and colleagues as information sources. For Infectious Diseases (ID) vignettes, participants identified questions about patients' clinical status at presentation and questions about disease classification, diagnosis/therapy/referral guidelines and sources of patient education. For ID vignettes, they identified history, laboratory results, colleagues, specialists and personal experience as information sources. CONCLUSION: Content analysis of office-based general pediatricians' responses to clinical vignettes provided a qualitative description of their perceptions of information needs and preferences for information resource for cases in Genetics and Infectious Diseases. This approach may provide complementary information for discovering practitioner's information needs and resource preferences in different contexts.

Adolescent↗
PubMed2005

Information retrieval performance of probabilistically generated, problem-specific computerized provider order entry pick-lists: a pilot study.

OBJECTIVE: The aim of this study was to preliminarily determine the feasibility of probabilistically generating problem-specific computerized provider order entry (CPOE) pick-lists from a database of explicitly linked orders and problems from actual clinical cases. DESIGN: In a pilot retrospective validation, physicians reviewed internal medicine cases consisting of the admission history and physical examination and orders placed using CPOE during the first 24 hours after admission. They created coded problem lists and linked orders from individual cases to the problem for which they were most indicated. Problem-specific order pick-lists were generated by including a given order in a pick-list if the probability of linkage of order and problem (PLOP) equaled or exceeded a specified threshold. PLOP for a given linked order-problem pair was computed as its prevalence among the other cases in the experiment with the given problem. The orders that the reviewer linked to a given problem instance served as the reference standard to evaluate its system-generated pick-list. MEASUREMENTS: Recall, precision, and length of the pick-lists. RESULTS: Average recall reached a maximum of .67 with a precision of .17 and pick-list length of 31.22 at a PLOP threshold of 0. Average precision reached a maximum of .73 with a recall of .09 and pick-list length of .42 at a PLOP threshold of .9. Recall varied inversely with precision in classic information retrieval behavior. CONCLUSION: We preliminarily conclude that it is feasible to generate problem-specific CPOE pick-lists probabilistically from a database of explicitly linked orders and problems. Further research is necessary to determine the usefulness of this approach in real-world settings.

Humans↗
PubMed2005

Why do patients and families request transfers to tertiary care? a qualitative study.

Interhospital transfers comprise a significant and increasing proportion of admissions to tertiary care centers. Patient dissatisfaction with the quality of hospital care may play an important role in these trends. The objective of this study was to describe why and how patients and surrogates request transfers to tertiary care. We interviewed 32 patients transferred to the Johns Hopkins Hospital, a US tertiary care center, or their surrogate decision-makers using a semi-structured, open-ended, iterative protocol. We used ethnographic decision modeling to develop an influence diagram of the decision. We contrasted subjects' perceptions of situations where patients did and did not request transfer to describe the threshold for requesting transfer. Subjects reported three major influences on the request to transfer to tertiary care: the quality of care at the community hospital compared to the tertiary center; the severity and potential consequences of the current illness; and their relationship with community hospitals, physicians, and tertiary care. Subjects' perceptions of the quality differential between community hospitals and tertiary centers focused on communication and medical errors rather than specialized care, hospital volume, or teaching status. Thresholds for when patients requested transfers were influenced by relationships with community hospitals and physicians and previous experience with tertiary care. This model provides a framework for understanding requests to transfer to tertiary care. Further investigation into the elements we have described might provide insights into improvements in the quality of care at community hospitals that might reduce the rates of requests for transfer. Our results also highlight the importance of including patient or surrogate perspectives in evaluations of the appropriateness of care.

Adult↗
PubMed2005

Chronic abdominal pain in children: a clinical report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

Children and adolescents with chronic abdominal pain pose unique challenges to their caregivers. Affected children and their families experience distress and anxiety that can interfere with their ability to perform regular daily activities. Although chronic abdominal pain in children is usually attributable to a functional disorder rather than to organic disease, numerous misconceptions, insufficient knowledge among health care professionals and inadequate application of knowledge may contribute to a lack of effective management. This clinical report accompanies a technical report on childhood chronic abdominal pain and provides guidance for the clinician in the evaluation and treatment of children with chronic abdominal pain. The conclusions are based on the evidence reviewed in the technical report and on consensus achieved among subcommittee members.

Abdominal Pain↗
PubMed2005

Inter-rater agreement in physician-coded problem lists.

Coded problem lists will be increasingly used for many purposes in healthcare. The usefulness of coded problem lists may be limited by 1) how consistently clinicians enumerate patients' problems and 2) how consistently clinicians choose a given concept from a controlled terminology to represent a given problem. In this study, 10 physicians reviewed the same 5 clinical cases and created a coded problem list for each case using UMLS as a controlled terminology. We assessed inter-rater agreement for coded problem lists by computing the average pair-wise positive specific agreement for each case for all 10 reviewers. We also standardized problems to common terms across reviewers' lists for a given case, adjusting sequentially for synonymy, granularity, and general concept representation. Our results suggest that inter-rater agreement in unstandardized problem lists is moderate at best; standardization improves agreement, but much variability may be attributable to differences in clinicians' style and the inherent fuzziness of medical diagnosis.

Forms and Records Control↗
PubMed2005

Workflow and problem domain as information planning tools in a pediatric clinic--defining present and future information technology needs.

In 2002, $22.4 billion were spent on hospital construction in the US. With lifetimes for new buildings expected to be decades, planning a building's information technology infrastructure must take into account present and future needs. Workflow measurement and the definition of problem domain have been advanced as essential tools in addressing current requirements while anticipating future needs. To examine these, stakeholders must be identified-including both those who will use the facility and those who will be involved in the IT planning and long term support.

Child↗
PubMed2005

Harriet Lane online culture book: matching residents' workflow.

Managing cultures taken from patients in a teaching outpatient setting, such as Johns Hopkins Harriet Lane Clinic (HLC) in Baltimore, is a complicated task to model,because it must support a task that lasts several days. There are many considerations in replacing the paper based system currently in place. We needed to balance the need for speed with the recognizability of familiar forms; the need for quality care with the need for teaching;and the need for documentation with the need for compact representation of clinical need.

Ambulatory Care Information Systems↗
PubMed2005

Web-based Bayesian Communication: the Bayesian z-test.

Bayesian Communication provides an explicit and quantitative way to combine a reader's preconceived notions with data from a study to help in making decisions, and thus implements the decision-analytic paradigm in the setting of interpreting and adapting research results. Article Assistant employs a three-tier architecture. The interface elicits users' prior belief and values; the article library provides data from the study, the system calculates the posterior belief distribution and sensitivity analysis on the fly, and provides an interpretation of the numerical results.

Bayes Theorem↗
PubMed2003

Impact of DOTS compared with DOTS-plus on multidrug resistant tuberculosis and tuberculosis deaths: decision analysis.

OBJECTIVE: This study sought to determine the impact of the World Health Organization's directly observed treatment strategy (DOTS) compared with that of DOTS-plus on tuberculosis deaths, mainly in the developing world. DESIGN: Decision analysis with Monte Carlo simulation of a Markov decision tree. DATA SOURCES: People with smear positive pulmonary tuberculosis. DATA ANALYSIS: Analyses modelled different levels of programme effectiveness of DOTS and DOTS-plus, and high (10%) and intermediate (3%) proportions of primary multidrug resistant tuberculosis, while accounting for exogenous reinfection. MAIN OUTCOME MEASURE: The cumulative number of tuberculosis deaths per 100 000 population over 10 years. RESULTS: The model predicted that under DOTS, 276 people would die from tuberculosis (24 multidrug resistant and 252 not multidrug resistant) over 10 years under optimal implementation in an area with 3% primary multidrug resistant tuberculosis. Optimal implementation of DOTS-plus would result in four (1.5%) fewer deaths. If implementation of DOTS-plus were to result in a decrease of just 5% in the effectiveness of DOTS, 16% more people would die with tuberculosis than under DOTS alone. In an area with 10% primary multidrug resistant tuberculosis, 10% fewer deaths would occur under optimal DOTS-plus than under optimal DOTS, but 16% more deaths would occur if implementation of DOTS-plus were to result in a 5% decrease in the effectiveness of DOTS CONCLUSIONS: Under optimal implementation, fewer tuberculosis deaths would occur under DOTS-plus than under DOTS. If, however, implementation of DOTS-plus were associated with even minimal decreases in the effectiveness of treatment, substantially more patients would die than under DOTS.

Cost-Benefit Analysis↗
PubMed2002

Testing strategies for diagnosing lupus anticoagulant: decision analysis.

Clinicians commonly evaluate patients with thrombosis or a prolonged activated partial thromboplastin time (aPTT) for the presence of a lupus anticoagulant (LA). We evaluated strategies for detecting LA, in three clinical settings, with decision-modeling techniques. A decision tree was constructed with 12 strategies, using a combination of aPTT and dilute Russell viper venom times (dRVVT) with confirmatory tests, tissue thromboplastin time (TTI), platelet neutralization procedures, and mixing studies. Probabilities and costs of adverse events and test costs were obtained from the literature. Patient preference for each strategy was evaluated by assigning utilities to each outcome. On the basis of assay results in 90 healthy people and 77 patients, we calculated sensitivities and specificities for each strategy, with true positives defined as suggested by the International Society on Thrombosis and Haemostasis. The least costly strategy for evaluation of patients with a prolonged aPTT, or with thrombosis, is not to test and to assume that LA is absent. For patients with systemic lupus erythematosus (SLE), it is least expensive not to test, although testing with TTI alone can also be considered an efficient strategy. The strategy of highest utility to patients with SLE is testing with TTI, followed by dRVVT. On the basis of these cost and utility results, clinicians' strategies for detecting LA may need modification. These strategies would then optimally be tested in clinical trials.

Abortion, Spontaneous↗
PubMed2002

Acne therapy: a methodologic review.

BACKGROUND: Acne is a very common problem with significant physical and psychological morbidity. The evidence basis for its treatment had not been systematically reviewed. Therefore, we performed an evidence review to provide researchers a basis for further studies, and to provide clinicians the background needed to interpret current and future clinical studies. OBJECTIVE: We summarize the methodologic state of the acne literature in patients with acne who do not have complicating co-morbidities. METHODS: This was an expert-advised literature synthesis. We used a structured literature search for English-language controlled trials in Cochrane CENTRAL, MEDLINE, OLDMEDLINE, HSTAT, CINAHL, and PsychInfo. Results underwent a structured data abstraction process, with review by at least 2 reviewers. RESULTS: Out of 1588 unique articles, 250 articles (274 controlled trials) over the past 50 years were reviewed: 57 (21%) trials had at least one major weakness and no strengths; 125 (47%) trials had at least one major strength and at least one major weakness; 48 (18%) trials had at least one major strength, and no major weaknesses. The remaining 16 (6%) were of intermediate quality or did not provide enough information to make a determination. One fourth of studies did not report patient age; one fourth did not report on patient gender. Only 8% mentioned patient race; only 2% mentioned skin type; 0.4% mentioned diet; none scored sexual maturity or insurance status. There were 1237 outcomes. There were more than 25 methods of assessing acne severity and more than 19 methods for counting lesions. There were only two trials that formally assessed psychological outcomes. More than 140 treatments were tested in 251 comparisons. CONCLUSION: Ranging over 50 years of research, the acne literature evidences great heterogeneity at all levels: patient characteristics, acne severity, outcome assessments, treatments, and comparisons. A list of methodologic recommendations is provided.

Acne Vulgaris↗
PubMedDate not supplied

Teaching cytopathology to second-year medical students. An interactive, case-based approach.

OBJECTIVE: To develop and implement an electronic, interactive, case-based cytopathology educational system for second-year medical students. STUDY DESIGN: Ten different learning modules, corresponding to various organ systems in pathology and encompassing the essence of clinical cytopathology, were developed. The modules are software-based, menu-driven, digital programs that are displayed on a computer monitor and can be projected onto a large screen via LCD projectors. Each module takes 15-20 minutes to complete and contains three to four case-based interactive clinical scenarios. Each case contains sequenced, multiple-choice questions with immediate feedback. Each module also includes an atlas mode for viewing all the case images plus additional images to enrich the learning experience. RESULTS: Preliminary feedback from students taking the pathology course has shown encouraging responses. The students enjoyed the practical approach of the modules, finding them easy to use. Their interest level remained high as they discovered how their general medical knowledge could apply to solving real-life clinical cytopathology cases. CONCLUSION: By utilizing these unique instructional modules in the second-year pathology course, medical students learn the application of clinical cytopathology in everyday medical practice. This not only provides them with the theoretical background and morphologic knowledge of the diseases taught but also gives them the ability to apply it in simulated real-life clinical scenarios.

Baltimore↗