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PubMed1994

Computer-based patient record: the essential data set approach.

The clamor for data to study the impact of care, to evaluate clinical performance and justify resource utilization is increasing. The data in demand normally should exist in the record of a clinical encounter. Advances in information technology and software techniques have provided us with tools to develop and implement computer-based patient record systems. The issues that constrain development are integral issues of clinical medicine, such as the variability in medical data, specialized practice of medicine, and differing demands of the numerous end-users of a medical record. This paper describes an approach to develop a computer-based patient record. The focus is on identification of the essential data set by infological data modeling and its implementation in a commercially available package for a physician's office.

Computer Systems↗
PubMed1994

The standard data model approach to patient record transfer.

This paper develops an approach to electronic data exchange of patient records from Ambulatory Encounter Systems (AESs). This approach assumes that the AES is based upon a standard data model. The data modeling standard used here is IDEFIX for Entity/Relationship (E/R) modeling. Each site that uses a relational database implementation of this standard data model (or a subset of it) can exchange very detailed patient data with other such sites using industry standard tools and without excessive programming efforts. This design is detailed below for a demonstration project between the research-oriented geriatric clinic at the Baltimore Veterans Affairs Medical Center (BVAMC) and the Laboratory for Healthcare Informatics (LHI) at the University of Maryland.

Computer Communication Networks↗
PubMed1994

An interactive learning environment for health care professionals.

This article summarizes experiences to date with building and deploying a clinical simulator that medical students use as part of a 3rd year primary care rotation. The simulated microworld helps students and health care professionals gain experience with and learn meta-cognitive skills for the care of complex patient populations that require treatment in the biopsychosocial-value dimensions. We explain lessons learned and next steps resulting from use of the program by over 300 users to date.

Computer Simulation↗
PubMed1994

A powerful macro-model for the computer patient record.

Especially in the Netherlands, the introduction of computer patient records (CPRs) in primary care has been relatively successful. Specialists usually maintain more extensive records than general practitioners and it has proven to be a great challenge to design a CPR that is useful and practical for specialized care. In this paper, we present the design of a CPR for use by specialists in an out-patient clinic. The philosophy underlying the design is that specialists may keep record in a relatively conventional way, while, at the same time, the system motivates them to add structure to their data. Data can be presented in various views, each suitable for one or more specific tasks. The potential to benefit from these views depends on the degree of structure in the recorded data. Since a CPR has to be faithful and permanent, explicit representation of observations, insights, and evolution of insight is also supported. The CPR system is in a final stage of implementation and will be evaluated in a clinical setting in summer 1994.

Computer Systems↗
PubMed1994

Generating patient-specific interactive natural language explanations.

Patient compliance is a significant problem and is strongly correlated with the patients' understanding of their condition and prescribed treatment. Since doctors typically do not have large amounts of time to educate patients, and impersonal, voluminous patient handouts are largely ineffective, we propose the use of a sophisticated computer-based information system to generate tailored, interactive handouts to communicate with patients. Our system uses text planning and user modeling techniques to generate natural language descriptions of migraine, its symptoms, triggering factors and prescriptions. The system is capable of handling follow-up questions requesting further information, and generating responses in the context of previously supplied information--a capability unavailable in previous patient information systems. The system tailors its interaction to: (i) the class of migraine patients, (ii) the individual patient, and (iii) the previous dialogue. Preliminary evaluation of the system indicates that patients find it useful and informative. More extensive evaluation is in progress.

Computer-Assisted Instruction↗
PubMed1994

An object-oriented tool for the generation and management of multimedia patient folders.

Computer-based patient folders are evolving from the simple reproduction of traditional paper documents toward active tools, able to support the whole diagnostic and therapeutic process. The advent of multimediality has given emphasys to the idea of computerized folder, i.e. a collection of heterogeneous kinds of documents pertaining different media. In this paper we present a tool implementing generation and management of multimedia patient folders showing its architecture and functionalities and the innovative interaction paradigms adopted. The tool realized allows medical users to choose the concepts desired in their target application and generates a customized patient folder management system by means of a friendly interface and without the need of a programming language. The system automatically created can be effectively employed for reporting and storing clinical cases.

Computer Systems↗
PubMed1994

Medical data capture and display: the importance of clinicians' workstation design.

The Department of Veterans Affairs is developing, testing and evaluating the benefits of physicians' workstations as an aid to medical data capture in an outpatient clinic setting. The physician's workstation uses a graphical user interface to aid the clinician in recording encounter data. Various input devices including keyboard, mouse, pen, voice, barcode reader, and tablet are available on the workstations, and user preferences will be examined. Access to general services such as electronic mail and reference databases is also available. The workstation provides a wide variety of patient specific data from the hospital information system, including image data. The single data collection process by the clinician will also provide data for the cost recovery process.

Computer Peripherals↗
PubMed1994

Multimedia clinical simulation based on patient records: authoring, user interface, pedagogy.

As an alternative to available computer-based clinical simulations that mimic patient encounters, we developed a clinical case simulation that more closely resembles the patient record. Our system, implemented in a Macintosh program called Short Rounds, features rapid and customized case authoring by editing a structured text file, a dynamic user interface that presents a case-specific screen layout, and a pedagogical model that is suitable for teaching third-year medical students. We believe this approach allows faculty members to create multimedia case simulations in shorter periods of time than in available clinical simulations.

Algorithms↗
PubMed1994

A cooperative model for integration in a cardiology outpatient clinic.

With the increasing amount of digitally stored patient information, such as images and findings, the possibility and need arise for a system which is able to both store and display this information in a structured, user-friendly way. In the common situation where different information systems are used within one department, this means that the various information systems have to be integrated. However, integration requires more complex management of data, processes and windows. This management can be handled by a Workspace Manager, which controls inter-application tasks, and interaction with the user. Furthermore, this Workspace Manager supports the user with the definition of complex tasks such as collecting problem-related patient information from the various remote systems. In an outpatient clinic for cardiology this architecture is used to achieve cooperative integration of an open Computer Patient Record with a range of information-specific services.

Ambulatory Care Facilities↗
PubMed1994

The development of a client application for the collaborative social and medical services system.

This paper describes the design and implementation of a client application for the Baylor College of Medicine Teen Health Clinics. The application is the front end to the Collaborative Social and Medical Services System (CSMSS) under development by Baylor's Medical Informatics and Computing Research Program [8]. The application provides distributed access to an underlying object oriented database system. A process driven and patient centered design will provide staff members with a complete set of services, including forms for data entry and viewing, query, and access management to facilitate efficient and effective delivery of services. Role-specific interfaces will be supplied for clerks, nurses, nurse practitioners, physicians, and social workers. The client application is being designed using object oriented methodologies and technologies with the C++ programming language, and will operate within a Microsoft Windows operating environment utilizing Object Linking and Embedding for application interoperability.

Adolescent↗
PubMed1994

Collaborative Social and Medical Service System.

This paper describes the Collaborative Social and Medical Services System, a robust information infrastructure for integrated social and medical care. The Collaborative Social and Medical Services System design and architecture address the primary goals of creating a readily extensible social and ambulatory care system. Our initial step toward reaching this goal is the delivery of an application supporting the operations of the Baylor Teen Health Clinics. This paper discusses our prototype experiences, system architecture, components, and the standards we are addressing.

Adolescent↗
PubMed1994

Automated medical knowledge acquisition: a study of consistency.

Knowledge bases are more representative of the population of medical experts if they are constructed by a group of individuals, rather than one practitioner. However, one runs into problems with consistency when information is elicited from a group without a consistent format and terminology. This study examines the consistency of relatively unconstrained computer-elicited medical knowledge using the computer program, KSSO. The results of this study show that the group of ten general internists were somewhat consistent in the diagnoses they listed for a patient presenting with chest pain. They were much less consistent in the findings they listed to differentiate between the diagnoses they had listed. The mean number of subjects listing each diagnosis was 3.3 +/- 2.7 while the mean for findings was 2.0 +/- 1.5. The implications of these data are discussed.

Artificial Intelligence↗
PubMed1994

Towards effective implementation of a pediatric asthma guideline: integration of decision support and clinical workflow support.

Successful local implementation of national guideline recommendations requires attention to factors that promote clinician compliance. Design of a computerized system is described that will implement recommendations from a recently published guideline for outpatient management of childhood asthma exacerbations. Logical analysis of the guideline shows that it is incomplete and contains several ambiguities that must be addressed before the guideline can be operationalized. Once the user-audience is defined guideline decision points are examined and a structured data entry system is devised. Support of clinicians' workflow is provided by an integrated capability for encounter documentation, dosage calculation, and prescription-writing. A pen-based, graphical interface represents an appropriate platform for implementation of the system because of its ease of use and portability.

Asthma↗
PubMed1994

Indexing guidelines: applications in use of pulmonary artery catheters and pressure ulcer prevention.

In a busy clinical environment, access to knowledge must be rapid and specific to the clinical query at hand. This requires indices which support easy navigation within a knowledge source. We have developed a computer-based tool for trouble-shooting pulmonary artery waveforms using a graphical index. Preliminary results of domain knowledge tests for a group of clinicians exposed to the system (N = 33) show a mean improvement on a 30-point test of 5.33 (p < 0.001) compared to a control group (N = 19) improvement of 0.47 (p = 0.61). Survey of the experimental group (N = 25) showed 84% (p = 0.001) found the system easy to use. We discuss lessons learned in indexing this domain area to computer-based indexing of guidelines for pressure ulcer prevention.

Abstracting and Indexing↗
PubMed1994

Interface for the documentation and compilation of a library of computer models in physiology.

A software interface for the documentation and compilation of a library of computer models in physiology was developed. The interface is an interactive program built within a word processing template in order to provide ease and flexibility of documentation. A model editor within the interface directs the model builder as to standardized requirements for incorporating models into the library and provides the user with an index to the levels of documentation. The interface and accompanying library are intended to facilitate model development, preservation and distribution and will be available for public use.

Computer Simulation↗
PubMed1994

The role of object representation in the design of the intelligent radiology workstation.

The paper describes the design of the Intelligent Radiology Workstation (IRW) that is intended to handle heterogeneous radiologic data (text, image, video) and radiologic knowledge in such a way that it is easy to store, access, use, and repurpose. An object-based structure is used to combine the relational database, hybrid knowledge base, and hypermedia within a common framework. Functions such as data entry and retrieval, browsing, and intelligent processing of data are available in the single environment. IRW open architecture allows radiologic digital resources to be used for clinical practice, diagnosis support, education, and research.

Artificial Intelligence↗
PubMed1994

Monitor-driven data visualization: SmartDisplay.

Exhaustive display of all available clinical data, particular in data-rich environments like the intensive care unit, can easily overwhelm the ability of clinicians to comprehend the clinical status and evolution of their patients and may reduce their ability to detect pathological trends in a reliable and timely manner. SmartDisplay is a system we have designed that restricts the data sets displayed to time-lines of those parameters that are relevant to the patient context and to the particular care provider. The relevance criteria are provided by monitoring programs which may range in complexity from simple threshold alarms to full-fledged diagnostic engines. SmartDisplay can specify which parameters to display and the time intervals during which they should be displayed.

Data Display↗
PubMed1994

Visualization and analysis of co-occurrence and cross-tabulation data in medical research.

Analyzing raw data can be prohibitively time consuming. A variety of graphical techniques have been developed to address this problem. Although graphical analysis can provide a simple yet comprehensive overview of a large dataset, often these techniques fail to capture the essence of data trends. In addition, the ability to easily query any component of the data subset frequently remains burdensome. In this paper, we present a general method to address these issues for cross-tabulation tables and provide examples of their use in medical research.

Computer Graphics↗