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An automated verbal medical history system.

Computer-based automated medical history acquisition systems have not been as widely utilized as originally anticipated. The high cost, limited accessibility and alien nature of the computer terminal equipment have all been cited as important factors in the limited acceptance. A system has been developed that makes it possible to use a standard household telephone as the computer input and output terminal in obtaining medical history data. Patient acceptance is excellent, and medical information gathered using this technique is as accurate as that obtained by self-administered questionnaires or personal interviews. This system maintains the advantages of the terminal-based automated history program while eliminating many of its deficiencies.

Computers↗

Review of the Naval Health Research Center's development of medical information systems for far-forward echelons of care, 1983 to 1997.

Medical treatment information must be gathered quickly and accurately to ensure continuity of care at far-forward echelons. The manual documentation methods in use during the Vietnam War revealed the need for considerable improvements in medical information documentation, patient tracking, and effective transfer of data throughout each of the first three echelons of care. The U.S. military determined that automation would result in the greatest enhancement of documentation techniques. The Naval Health Research Center (NHRC) has been an integral part of the development of medical information systems for the Navy's far-forward echelons of care. The prototypes designed by NHRC for echelons I and II can successfully raise the standard of treatment while simultaneously reducing the number of individuals needed for administrative duties and increasing the number of medical staff available for patient care. An overview of NHRC's work in medical information systems from 1983 to 1997 is presented.

Humans↗

Educational applications of a knowledge-based expert system for medical decision making in hepatology.

An expert system for medical decision making in hepatology has been developed with the aim of assisting medical education. The knowledge representation is based on different slots respectively concerned with structural and protypical description, and system control. Reasoning is performed at two levels considering in sequence syndromes and diseases. Explanations are available at any time during the reasoning process. Educational facilities are provided by using the help sections of the system, which include definitions and descriptions of finding in both health and disease, as well as summaries defining essential clinical and pathophysiological features of all diagnostic hypotheses. The system provides the following educational functions: support to medical decision making, differential diagnosis, knowledge-base consultation, system description and clinical simulation. A good correspondence was found between the conclusions and suggestions provided by the system and those of the attending physicians. The program, which was written in PROLOG and developed under MS-DOS Operating System, runs on IBM-compatible personal computers equipped with hard-disk and mouse.

Computer Systems↗

Knowledge based expert systems for medical diagnosis.

Knowledge based expert systems' have been developed in the last decade for many different applications by adopting artificial intelligence techniques. The paper discusses the main characteristics of the expert systems devoted to medical diagnosis (knowledge representation, explanation capability, inexact reasoning) and addresses some of the limitations (mainly system validation and knowledge acquisition). Finally the paper sketches the overall organization of an expert system devoted to the evaluation of liver function.

Artificial Intelligence↗

The formation of the emergency medical services system.

The evolution of the emergency medical services system in the United States accelerated rapidly between 1960 and 1973 as a result of a number of medical, historical, and social forces. Current emergency medical services researchers, policy advocates, and administrators must acknowledge these forces and their limitations and work to modify the system into one that provides uniformly high-quality acute care to all patients, improves the overall public health through injury control and disease prevention programs, participates as a full partner in disease surveillance, and is prepared to address new community needs of all types.

Emergency Medical Services↗

Disaster modeling: medication resources required for disaster team response.

INTRODUCTION: Responses to disasters involve many factors beyond personnel, such as medical and non-medical equipment and supplies. When disaster teams respond, they must do so with sufficient amounts of medicine and supplies to manage all of the patients expected for several days before re-supply. In order for this process to be efficient and expedient, accurate and advanced planning for supplies needed by disaster workers is necessary. These supplies must provide for general medical care and for hazard-specific problems. OBJECTIVE: To develop a model that provides the framework for determining supply requirements for the National Disaster Medical System, Disaster Medical Assistance Teams, or other responding disaster teams in a civilian environment. METHODS: A community hospital was modeled to determine patient characteristics when presenting to an emergency department (ED), including patient demographics and chief complaint, medications administered during the ED visit and prescribed at discharge, and laboratory tests ordered to assess disaster team supply requirements. Data were downloaded from a patient tracking software package and abstracted from various hospital data information systems. Data from the community hospital were compared with data published from two hurricane disasters by members of the National Disaster Medical System. RESULTS: To the extent possible, the model predicted the proportion of patient complaints and, therefore, the medicine and supplies needed for the management of these patients. CONCLUSION: This model offers a first step in preparing disaster medical teams for deployment.

Adolescent↗

DXplain: a Web-based diagnostic decision support system for medical students.

DXplain is a diagnostic decision support program, with a new World Wide Web interface, designed to help medical students and physicians formulate differential diagnoses based on clinical findings. It covers over 2000 diseases and 5000 clinical manifestations. DXplain suggests possible diagnoses, and provides brief descriptions of every disease in the database. Not all diseases are included, nor does DXplain take into account preexisting conditions or the chronological sequence of clinical manifestations. Despite these limitations, it is a useful educational tool, particularly for problem-based learning (PBL) cases and for students in clinical rotations, as it fills a niche not adequately covered by MEDLINE or medical texts. The system is relatively self-explanatory, requiring little or no end-user training. Medical libraries offering, or planning to offer, their users access to Web-based materials and resources may find this system a valuable addition to their electronic collections. Should it prove popular with the local users, provision of access may also establish or enhance the library's image as a partner in medical education.

Clinical Clerkship↗

Building national electronic medical record systems via the World Wide Web.

Electronic medical record systems (EMRSs) currently do not lend themselves easily to cross-institutional clinical care and research. Unique system designs coupled with a lack of standards have led to this difficulty. The authors have designed a preliminary EMRS architecture (W3-EMRS) that exploits the multiplatform, multiprotocol, client-server technology of the World Wide Web. The architecture abstracts the clinical information model and the visual presentation away from the underlying EMRS. As a result, computation upon data elements of the EMRS and their presentation are no longer tied to the underlying EMRS structures. The architecture is intended to enable implementation of programs that provide uniform access to multiple, heterogeneous legacy EMRSs. The authors have implemented an initial prototype of W3-EMRS that accesses the database of the Boston Children's Hospital Clinician's Workstation.

Boston↗

[A program for medical use of information systems. Validity of calculation of direct costs for the initial treatment of acute myeloblastic leukemia].

In order to validate the information systems medicalization program used since 1984 at the Hôtel-Dieu hospital, Paris, the direct costs given by this program were compared with those calculated from the medical records of 10 adult patients hospitalized for diagnosis and treatment of acute myeloblastic leukaemia. The mean direct cost of an 8 to 81 days hospital stay was estimated at 75.393 +/- 41.260 French francs by the program and 84.969 +/- 52.288 FF by calculations from the records. A fairly good correlation (r2 = 0.72; P = 0.002) was found between the 2 evaluations. There was no statistically significant difference between the figures obtained by the 2 methods, except for pharmaceutical expenditures (P = 0.005) which were grossly underevaluated by the program. A better correlation could be obtained if an attribution of drugs and transfusions per patient was entered in the program.

Adult↗

New endometrial ablation techniques for treatment of menorrhagia.

Endometrial ablation is an excellent alternative to hysterectomy in women with menorrhagia and small intramural fibroids. Preoperative evaluation, which includes office hysteroscopy or saline infusion sonography, is critical to patient management and choice of procedure. A vast array of endometrial ablation technology is available currently that includes balloon therapy, cryosurgery hot circulating saline, bipolar impedance technology, and microwave: (1) ThermaChoice UTB System (Gynecare, Inc., Somerville, NJ, USA), (2) Uterine Balloon Therapy (UBT) System, HerOption Uterine Cryoblation Therapy System (American Medical Systems, Inc., Minnetonka, MN, USA), (3) Hydro ThermAblator HTA System (BEI Medical/Boston Scientific, Natick, MA), (4) NovaSure System (Novacept, Palo Alto, CA, USA), and (5) Microsulis Microwave Endometrial Ablation (MEA) System (Microsulis Medical Ltd., Pompano Beach, FL, USA). Each method is described herein, and Summary of Safety and Effectiveness Data (SSED) data for each product are reviewed.

Balloon Occlusion↗

Recent status of the medical examiner system in Japan: demographic variation of medicolegal deaths in Hyogo Prefecture and uncertainty in medicolegal investigations conducted by medical practitioners.

The medical examiner system has been steadily abolished in Japan. Instead, medicolegal investigations are entrusted by the police to medical practitioners, who are not permitted to perform autopsies. The necessity for the medical examiner system was assessed through inquest records in Hyogo, one of the three prefectures which still have medical examiner systems. Standardized mortality ratios (SMRs) for accidents and suicides were negatively associated with population density, being high in rural areas with a large proportion of elderly citizens, while the SMR for natural deaths was high in urbanized areas and associated with the proportion of inquests to total resident deaths. The high proportion of inquests, however, did not always mean that inquest records were of good quality. Significant differences in the quality of medicolegal investigations seemed to exist between medical examiners and medical practitioners. That is, in order to certify the cause-of-death, medical examiners performed autopsies in about half of their cases, while only 2% of medical practitioner cases were subjected to autopsies. Medical practitioners, who certified the cause-of-death as "heart failure" without advising an autopsy, were regularly entrusted with inquests. It is likely that the causes-of-death for medicolegal cases may be questionable since more than 85% of all medicolegal deaths were investigated by medical practitioners, which may cause inaccuracy in at least 3-7% of mortality statistics. It is necessary to educate medical practitioners concerning the importance of mortality statistics and ICD and on the validity of autopsies, in order to obtain accurate mortality statistics from medicolegal cases.

Accidents↗

Task-oriented evaluation of electronic medical records systems: development and validation of a questionnaire for physicians.

BACKGROUND: Evaluation is a challenging but necessary part of the development cycle of clinical information systems like the electronic medical records (EMR) system. It is believed that such evaluations should include multiple perspectives, be comparative and employ both qualitative and quantitative methods. Self-administered questionnaires are frequently used as a quantitative evaluation method in medical informatics, but very few validated questionnaires address clinical use of EMR systems. METHODS: We have developed a task-oriented questionnaire for evaluating EMR systems from the clinician's perspective. The key feature of the questionnaire is a list of 24 general clinical tasks. It is applicable to physicians of most specialties and covers essential parts of their information-oriented work. The task list appears in two separate sections, about EMR use and task performance using the EMR, respectively. By combining these sections, the evaluator may estimate the potential impact of the EMR system on health care delivery. The results may also be compared across time, site or vendor. This paper describes the development, performance and validation of the questionnaire. Its performance is shown in two demonstration studies (n = 219 and 80). Its content is validated in an interview study (n = 10), and its reliability is investigated in a test-retest study (n = 37) and a scaling study (n = 31). RESULTS: In the interviews, the physicians found the general clinical tasks in the questionnaire relevant and comprehensible. The tasks were interpreted concordant to their definitions. However, the physicians found questions about tasks not explicitly or only partially supported by the EMR systems difficult to answer. The two demonstration studies provided unambiguous results and low percentages of missing responses. In addition, criterion validity was demonstrated for a majority of task-oriented questions. Their test-retest reliability was generally high, and the non-standard scale was found symmetric and ordinal. CONCLUSION: This questionnaire is relevant for clinical work and EMR systems, provides reliable and interpretable results, and may be used as part of any evaluation effort involving the clinician's perspective of an EMR system.

Cooperative Behavior↗

C3: Java-based medical record system for cardiology.

This paper describes a system for electronic medical record (EMR) we have developed for use in our health care institution, mainly dealing with diagnosis and treatment of cardiovascular pathologies. This activity is part of the project SPERIGEST, supported by Health Ministry of Italy, for the management of health care delivery, as concerns both clinical and administrative aspects. A networked computer-based information system was realized to integrate the different heterogeneous sources of patient information. Both clinical and administrative patient relevant data are provided from the various systems and stored into a central database. The EMR system was designed using World Wide Web (WWW) technology (Java, HTML). The system is currently under clinical evaluation.

Cardiology↗

The internet-based knowledge acquisition and management method to construct large-scale distributed medical expert systems.

The Internet offers an unprecedented opportunity to construct powerful large-scale medical expert systems (MES). In these systems, a cost-effective medical knowledge acquisition (KA) and management scheme is highly desirable to handle the large quantities of, often conflicting, medical information collected from medical experts in different medical fields and from different geographical regions. In this paper, we demonstrate that a medical KA/management system can be built upon a three-tier distributed client/server architecture. The knowledge in the system is stored/managed in three knowledge bases. The maturity of the medical know-how controls the knowledge flow through these knowledge bases. In addition, to facilitate the knowledge representation and application in these knowledge bases as well as information retrieval across the Internet, an 8-digit numeric coding scheme with a weight value system is proposed. At present, a medical KA and management system based on the proposed method is being tested in clinics. Current results have showed that the method is a viable solution to construct, modify, and expand a distributed MES through the Internet.

Computer Systems↗

Conflicting view support by medical information systems.

One of the advantages of current database systems is the capability to enforce global integrity constraints on a large amount of data. Input of contradicting data will be rejected by database systems in order to maintain correctness. On the other hand, in medical information systems it may be necessary to realize two or more databases in one system, where there are some controlled contradictions among these databases. For example, if a doctor wants to hide the real disease name from the patient in critical condition, the database viewed by the patient should be different from the real database, although each of these databases should be conflict free and large amounts of data are shared by both. This kind of problem was not discussed for commercial business-oriented databases. Data sharing and data security are important functions required for medical information systems. There are, however, cases when we need to show non-real data to some users. Security mechanisms usually prevent a user from retrieving critical data. If a request for retrieval of some data is rejected by the system, a user may find there is something secret being kept from him. In order to cope with these situations, we introduce the POSTGRES database system. POSTGRES is a generalized relational database system developed at the University of California. The form of POSTGRES rule is as follows: On event (To) object WHERE POSTQUEL-qualification Then Do [instead] POSTQUEL-command(s) The POSTGRES rule shows that event is retrieve, replace, delete, append, new (i.e., replace or append) or old (i.e., delete or replace). The concept of objects is introduced in object-oriented databases. In relational database systems, an object corresponds to each data value, an attribute, or a relation. The optional keyword "instead" indicates that the action indicated by POSTQUEL-command(s) is to be performed instead of the action which caused the rule to activate. This keyword plays very important role for our purpose. By preparing a standard story which is consistent with the patient's condition, the doctor can make a smooth explanation to the patient showing the stories instead of the critical data. So, if medical personnel and system designers prepare the standard stories or data for the explanation and store such data in the system, the users of medical information systems (doctors) can take the benefit of the data replacement. For such a purpose, medical personnel and system designers classify the patients' data according to their age, sex, occupational history, personal history, and diseases. Standard story or data should be prepared for each user class in advance. Using POSTGRES rule system in medical information systems, doctors can make a smooth explanation of a patientUs condition in serious cases, when hiding real data is required. The validity of POSTGRES rule system is proved where data exchange is needed for data protection. For example, when a doctor writes a prescription of a placebo through the ordering system, POSTGRES rule system will identify its existence. We believe that POSTGRES rule system can be applied to many fields in medical data processing.

Confidentiality↗

Multiple representations and multi-modal reasoning in medical diagnostic systems.

The paper examines the motivations for developing medical diagnostic systems exploiting multiple representations and multi-modal reasoning. The analysis is carried on by revisiting the architectural choices of the CHECK system (developed in late 1980s) which combined heuristic and causal knowledge. The results in the theory of diagnosis and in model-based reasoning (MBR) obtained in early 1990s are used for providing a formal characterization of the notion of diagnosis and of the reasoning mechanisms used in CHECK. The paper addresses also the problem of replacing heuristic knowledge provided by human experts with operational knowledge automatically derived from the deep model. In particular, the pros and cons of knowledge compilation and of the integration of case-based reasoning (CBR) with MBR are discussed by summarizing the experience gained in developing AID and ADAPtER. The problem of using an explicit representation of time in diagnostic systems is analyzed and recent work on the different characterizations of diagnosis arising when the temporal dimension is considered is reported. Finally, the implications of the results obtained in MBR and in temporal reasoning on the future of medical diagnostic systems are briefly discussed.

Artificial Intelligence↗

Physician use of an ambulatory medical record system: matching form and function.

An ambulatory medical record system was implemented as a pilot project to determine the clinical and operational impacts of using interactive, computer-based systems in the outpatient setting. Of the 58 physicians who attempted to use the AMR system, 28 continue as active users. Physicians who discontinued use of the system reported a variety of reasons for their dissatisfaction. As a result of the pilot, the AMR implementation team and physicians understand better how to fit the AMR system to a physician's specific requirements, as well as enhance the operation of the physician's practice. Armed with the experience gained during the early phases of the implementation, the Cleveland Clinic Foundation now intends a cautious expansion and continued evaluation of the AMR system, with the objective of meeting organizational needs with appropriate technical functions.

Ambulatory Care Information Systems↗