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During 1990, 83 patients seen for a general physical examination at a family practice clinic completed a computer-based health risk appraisal in one of two formats, batch or interactive. They also completed a written questionnaire on their health risks and knowledge before taking the appraisal, and 65 of them completed another health risk appraisal and questionnaire three months later. No difference in user evaluation of the appraisal regarding its helpfulness, their intent to change behavior based on the appraisal, or amount learned from the appraisal was found between batch and interactive formats. About half (48%) of the individuals correctly estimated their overall health risks before taking the health risk appraisal. Among those who initially misjudged their health risks, few women adjusted their health risk rating at followup. Men showed a tendency to adjust their rating to more closely agree with the health risk appraisal estimates although the differences are not statistically significant. Eighty percent of the men and 55% of the women accurately rated their overall risk at followup. Knowledge of specific causes of death did not improve at followup.
The successful introduction of a new information system requires technological and behavioral changes. Intended users of the new system should participate in defining goals for the system, examining alternatives for achieving these goals, and selecting from these alternatives. Broad-based end-user involvement is especially useful during the needs assessment (goal definition) phase, both to identify the diverse expectations of the end-user community and to develop a sense of system ownership by these users. System planners can stimulate active end-user involvement by inviting each constituent user group (for example, each hospital department) to assume responsibility for specifying its objectives for the new system. The collection of all groups' objectives defines the organization's expectations of a new system, provides a means for comparing systems, and aids in predicting the overall acceptance of any proposed system. Each constituent group's list of objectives likewise provides a measure of anticipated acceptance for that group.
To optimize blood ordering and accurately assess transfusion practice, in 1987, an "on line" computerized, knowledge-based, blood order critiquing system was integrated into the HELP Hospital Information System (HIS) at LDS Hospital. Evaluations of the computerized ordering system demonstrated its benefits and limitations on transfusion practice. Based on this experience, a second generation blood ordering system using a consultation mode was developed. A pilot test of this blood order consultant system, using historical data in the HELP system's database, was performed. This pilot test demonstrated that the consultation system provided accurate recommendations for red blood cell (RBC) and platelet orders. Comparing the appropriateness of blood orders with the recommendations made by the director of the blood bank, the orders recommended by the computer "consultant" agreed 95.5% of the time. The computer consultation system also recommended fewer RBC units for transfusion. Preliminary results obtained using the consultant approach suggest that we may be able to simplify blood ordering practice and also reduce the number of units of blood products ordered. Based on these findings we are now preparing to compare the "critiquing" and "consultation" approaches using a clinical trial.
In the lifecycle of epidemiologic data three steps can be identified: production, interpretation and exploitation for decision. Computerized support can be precious, if not indispensable, at any of the three levels, therefore several epidemiologic data management systems were developed. In this paper we focus on intelligent management of epidemiologic data, where intelligence is needed in order to analyze trends or to compare observed with reference value and possibly detect abnormalities. After having outlined the problems involved in such a task, we show the features of ADAMS, a system realized to manage aggregated data and implemented in a personal computer environment.
We tested a new model of the HELP patient database that makes use of relational tables to store patient data and provides access to data using SQL (Structured Query Language). The SQL database required more storage space and had many more physical records than the HELP database, but it was faster and more efficient in storing data than the standard HELP utilities. The HELP utilities used disk space more efficiently and were faster than the SQL tools when retrieving data for typical clinical reports. However, the SQL model provides networking capabilities, general report writing tools, detailed user documentation, and an ability for creating secondary indexes that offset its poorer performance.
A great many clinics are interested in using software programs in daily practice. We report on the construction of a time oriented medical record unit (TOMRU). It runs on MS-DOS personal computers. TOMRU handles the follow-up data of ambulatory patients. Of the possible database customizations allowed by TOMRU, the cardiology patient database (TOMRU/C) and hypertensive patient database (TOMRU/H) were developed and are described here. Customizing TOMRU should in any case be left to an expert user, in charge of database management. The clinical information to be included in the customizations was obtained by discussing the needs of and obtaining the consensus of clinical practitioners. TOMRU/C was handed over to some hundreds of clinical centres during the computerized itinerant courses held to train users.
The Care Windows development project demonstrated the feasibility of an approach designed to add the benefits of an event-driven, graphically-oriented user interface to an existing Medical Information Management System (MIMS) without overstepping economic and logistic constraints. The design solution selected for the Care Windows project incorporates three important design features: (1) the effective de-coupling of severs from requesters, permitting the use of an extensive pre-existing library of MIMS servers, (2) the off-loading of program control functions of the requesters to the workstation processor, reducing the load per transaction on central resources and permitting the use of object-oriented development environments available for microcomputers, (3) the selection of a low end, GUI-capable workstation consisting of a PC-compatible personal computer running Microsoft Windows 3.0, and (4) the development of a highly layered, modular workstation application, permitting the development of interchangeable modules to insure portability and adaptability.
The increasing availability of medical information resources has moved the "Medical Desktop" from a theoretical construct to a practical necessity. Many micro-computers are becoming available in clinical and academic settings that can access several medical information applications. These computers are usually not powerful workstations that are part of a clinically oriented information support system, but are personal computers with varied capabilities. The applications on these computers come from different sources, are accessed through different user interfaces and do not share data well. The de facto "Medical Desktop" this situation presents will discourage most end-users because the combination of applications is complex, the applications are poorly integrated, and individual applications are inconsistent. At the State University of New York at Buffalo School of Medicine and Biomedical Sciences we have developed several Microsoft Windows-based tools that accept a systems level diversity of resources, but work toward the construction of a coherent "Medical Desktop." These tools include a lexical term linker, a resource database, and a context sensitive help system that is tailored to locally available resources.
Casebook is a clinically oriented database, written in MUMPS, and designed for recording the clinical encounters of medical students at Harvard Medical School. Its main goals are to 1) increase student use of computer technology, 2) help faculty evaluate the diversity of clinical experiences on their service, 3) provide data to the faculty on the "typical" experience of medical students on their service to aid in the evaluation of the curriculum and, 4) provide report-generation capabilities for the students to improve dialog with their preceptors. Students are able to enter information on "Problems" and "Procedures" selecting from a pop-up menu of medical terms or by entering free text. Casebook is currently in use in the Medicine, OB/GYN, Pediatric and Ambulatory rotations. At sites where the faculty take an active interest in the use of Casebook students perceive it to be valuable and subsequently use it more frequently. It is currently being expanded for use by medical students in their second, third, and fourth years of school.
We describe a multimedia program for teaching anatomy. The program, called the Anatomy Browser, displays cross-sectional and topographical images, with outlines around structures and regions of interest. The user may point to these structures and retrieve text descriptions, view symbolic relationships between structures, or view spatial relationships by accessing 3-D graphics animations from videodiscs produced specifically for this program. The software also helps students exercise what they have learned by asking them to identify structures by name and location. The program is implemented in a client-server architecture, with the user interface residing on a Macintosh, while images, data, and a growing symbolic knowledge base of anatomy are stored on a fileserver. This architecture allows us to develop practical tutorial modules that are in current use, while at the same time developing the knowledge base that will lead to more intelligent tutorial systems.
The goal of the UMLS Project is to give practitioners and researchers easy access to machine-readable information from diverse sources. Assessment of the first experimental versions of the UMLS Knowledge Sources is essential to measuring progress toward that goal and to identifying needed enhancements. As of July 30, 1991, copies of the first edition of the UMLS Knowledge Sources had been distributed to 143 individuals and institutions; 66 had provided initial feedback information. The information received indicates that the UMLS Knowledge Sources will undergo broad testing in the patient care, medical education, library service, and product development environments. Preliminary data support the hypothesis that expanded coverage of routine clinical concepts is needed. Key enhancements planned for 1992 and beyond include expanded coverage of ICD-9-CM and CPT.
A workstation designed to facilitate electronic charting in the intensive care unit is described. The system design incorporates a graphical, windows-based user interface. The system captures all data formerly recorded on the paper flowsheet including direct patient measurements, nursing assessment, patient care procedures, and nursing notes. It has the ability to represent charted data in a variety of graphical formats, thereby providing additional insights to facilitate the management of the critically ill patient. Initial nursing evaluation is described.
To ensure tight coupling between users' work practices and the system's model of these practices, designers need methods to generate accurate descriptions of what users actually do. This paper illustrates how we model physicians' information needs and translate knowledge about these needs into design specifications.
Evaluation in medical informatics tends to follow the paradigm of controlled clinical trials. This model carries with it a number of assumptions whose implications for medical informatics deserve examination. In this paper, we describe the conventional wisdom on evaluation, pointing out some of its underlying assumptions and suggesting that these assumptions are problematic when applied to some aspects of evaluation. In particular, we believe that these assumptions contribute to the problem of user acceptance. We then suggest a broader approach to evaluation, offering some conceptual and methodological distinctions that we believe will be of use to the medical informatics community in rethinking this issue.
WALT (Washington University's Approach to Lots of Text), is a prototype interface designed to support information retrieval research. The WALT interface serves as a "front end" to a wide array of retrieval engines including those based on Boolean retrieval, latent semantic indexing, term frequency--inverse document frequency, and Bayesian inference techniques. The WALT interface is composed of seven distinct components: a document examination component known as the Document Browsing Area; four navigation components called the Book Shelf, the Book Spine, the Table of Contents, and the Path Clipboard; a term-based information retrieval component called Control Panel; and a relevance feedback component known as the Reader Feedback Panel. WALT's most unique feature may be it's use of "book shelf" and "book spine" metaphors both to facilitate navigation and to provide a histogram-based display showing documents deemed appropriate for answering user queries.
The lack of user acceptance for many medical decision-support systems should force medical software developers to rethink strategies for user interaction with decision-support programs. Participatory design is an emerging method for the development for computer applications that emphasizes user involvement in both the design and implementation phases. We have applied participatory design to the development of a user interface for VentPlan, an application that assists physicians in the management of artificial respiration of critically ill patients. In this paper, we present a case history of the participatory design process and describe the resulting interface for the VentPlan program. As a result of applying participatory design ideas, we gained insight as to how to implement VentPlan more effectively.
Because physicians have been reluctant to accept computerized medical records systems, we sought to identify the barriers to acceptance and redesigned our ambulatory records system accordingly. We identified several problems physicians encounter in using our computerized medical record system (COSTAR), including physicians' hesitation to use a computer in front of their patients, physicians' poor keyboard skills, and the structural organization of the computerized medical record. We formed a users group to educate users and the group has helped identify solutions to these problems. We equipped the exam room terminals with a user-friendly, patient-specific menu. We created a new physician interface for COSTAR that was organized to function similarly to a patient's chart and features user-friendly menus that provide cues to the unsophisticated user. Physician use of exam room terminals tripled after the installation of the exam room menu. The new physician interface doubled physician use of COSTAR's scheduling features. Acceptance of the new interface as gauged by a user survey was excellent, with the majority stating it improved their patient care.