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PubMed1997

Bridging the gap between managed care and academic medicine: an innovative fellowship.

Numerous challenges face academic medicine in the era of managed care. This environment is stimulating the development of innovative educational programs that can adapt to changes in the healthcare system. The U.S. Quality Algorithms Managed Care Fellowship at Jefferson Medical College is one response to these challenges. Two postresidency physicians are chosen as fellows each year. The 1-year curriculum is organized into four 3-month modules covering such subjects as biostatistics and epidemiology, medical informatics, the theory and practice of managed care, managed care finance, integrated healthcare systems, quality assessment and improvement, clinical parameters and guidelines, utilization management, and risk management. The fellowship may serve as a possible prototype for future post-graduate education.

Algorithms↗
PubMed1994

An investigation of barriers to computer-based patient record implementation.

A study was conducted to verify barriers to implementing computer-based patient record systems as perceived by a random sample of members of the American Health Information Management Association, the American Medical Informatics Association, and the Health Information Management and Systems Society. Study respondents were asked to identify the likelihood of their institution overcoming the barriers and which, if any, strategies would be most helpful in overcoming them. This article discusses the study results.

Analysis of Variance↗
PubMed1998

Intelligent agent for collaborative diagnosis.

An agent-based approach to facilitating cooperative medical diagnosis is presented in this paper. Background work in computer supported cooperative work and medical informatics is first discussed. Relevant theory for interaction management is then considered. An agent-based interaction is then shown via a case study to facilitate cooperative diagnosis. This is achieved through monitoring patient record construction and by highlighting relevant diagnostic information.

Computer Communication Networks↗
PubMed1995

A portable communicative architecture for electronic healthcare records: the Good European Healthcare Record project (Aim project A2014).

The European Union is supporting research into medical informatics via its Advanced Informatics in Medicine (AIM) program. One of the current AIM projects is the Good European Healthcare Record (GEHR) project. Its objective is to devise an architecture for electronic healthcare records that will enable them to be comprehensive, communicative, and portable to different systems. The work was funded from January 1992 to December 1994. The project team consisted of over 50 personnel representing clinicians, computer scientists, and computer programmers in eight European countries. The partner organizations are Health Data Management Partners (Belgium), Croix Rouge Francaise (France), France Telecom, Association des Medecins et Medicins Dentistes (Luxembourg), Instituto Clinica Geral Zona Norte (Portugal), Medical College of St Bartholomew's Hospital (UK), and SmithKline Beecham (UK). The work of the project has been carried out by three subgroups covering clinical, architecture, and systems aspects. One of the strengths of the project has been that most of the work has been done as collaborations between members of different groups. This has meant that there has been very close contact between clinicians and computer experts. The GEHR project is providing important input into the standardization process in Europe via, for example, PT011 of Working Group 1 of CEN TC/251 (the developing standards for the architecture of healthcare records).

Computer Communication Networks↗
PubMed1995

An intelligent interactive system for delivering individualized information to patients.

This paper is a report on the first phase of a long-term, interdisciplinary project whose goal is to increase the overall effectiveness of physicians' time, and thus the quality of health care, by improving the information exchange between physicians and patients in clinical settings. We are focusing on patients with long-term and chronic conditions, initially on migraine patients, who require periodic interaction with their physicians for effective management of their condition. We are using medical informatics to focus on the information needs of patients, as well as of physicians, and to address problems of information exchange. This requires understanding patients' concerns to design an appropriate system, and using state-of-the-art artificial intelligence techniques to build an interactive explanation system. In contrast to many other knowledge-based systems, our system's design is based on empirical data on actual information needs. We used ethnographic techniques to observe explanations actually given in clinic settings, and to conduct interviews with migraine sufferers and physicians. Our system has an extensive knowledge base that contains both general medical terminology and specific knowledge about migraine, such as common trigger factors and symptoms of migraine, the common therapies, and the most common effects and side effects of those therapies. The system consists of two main components: (a) an interactive history-taking module that collects information from patients prior to each visit, builds a patient model, and summarizes the patients' status for their physicians; and (b) an intelligent explanation module that produces an interactive information sheet containing explanations in everyday language that are tailored to individual patients, and responds intelligently to follow-up questions about topics covered in the information sheet.

Anthropology, Cultural↗
PubMedDate not supplied

Implementation of a province-wide computerized network in Quebec: the FAMUS Project.

General practitioners have busy schedules and are accustomed to working autonomously. But they will take an interest in research issues that could increase their efficiency or improve patient care. The use of medical informatics tools to facilitate collaborative research networks requires that participants accept the tools. This article describes the implementation of a province-wide computing network and discusses the opportunities afforded by the creation of a large central database documenting the process of care.

Ambulatory Care Information Systems↗
PubMed1998

Measuring the quality of diagnostic hypothesis sets for studies of decision support.

Within medical informatics there is widespread interest in computer-based decision support and the evaluation of its impact. It is widely recognized that the measurement of dependent variables, or outcomes, represents the most challenging aspect of this work. This paper describes and reports the reliability and validity of an outcome metric for studies of diagnostic decision support. The results of this study will guide the analytic methods used in our ongoing multi-site study of the effects of decision support on diagnostic reasoning. Our measurement approach conceptualizes the quality of a diagnostic hypothesis set as having two components summed to generate a composite index: a Plausibility Component derived from ratings of each hypothesis in the set, whether correct or incorrect; and a Location Component derived from the location of the correct diagnosis if it appears in the set. The reliability of this metric is determined by the extent of interrater agreement on the plausibility of diagnostic hypotheses. Validity is determined by the extent to which the index generates scores that make sense on inspection (face validity), as well as the extent to which the component scores are non-redundant and discriminate the performance of novices and experts (construct validity). Using data from the pilot and main phases of our ongoing study (n = 124 subjects working 1116 cases), the reliability of our diagnostic quality metric was found to be 0.85-0.88. The metric was found to generate, on inspection, no clearly counterintuitive scores. Using data from the pilot phase of our study (n = 12 subjects working 108 cases), the component scores were moderately correlated (r = 0.68). The composite index, computed by equally weighting both components, was found to discriminate the hypotheses of medical students and attending physicians by 0.97 standard deviation units. Based on these findings, we have adopted this metric for use in our further research exploring the impact of decision support systems on diagnostic reasoning and will make it available to the informatics research community.

Decision Support Systems, Clinical↗
PubMedDate not supplied

On lossy transform compression of ECG signals with reference to deformation of their parameter values.

Electrocardiogram (ECG) signals are the most prominent biomedical signal type used in clinical medicine. Their compression is important and widely researched in the medical informatics community. In the previous literature compression efficacy has been investigated only in the context of how much known or developed methods reduced the storage required by compressed forms of original ECG signals. Sometimes statistical signal evaluations based on, for example, root mean square error were studied. In previous research we developed a refined method for signal compression and tested it jointly with several known techniques for other biomedical signals. Our method of so-called successive approximation quantization used with wavelets was one of the most successful in those tests. In this paper, we studied to what extent these lossy compression methods altered values of medical parameters (medical information) computed from signals. Since the methods are lossy, some information is lost due to the compression when a high enough compression ratio is reached. We found that ECG signals sampled at 400 Hz could be compressed to one fourth of their original storage space, but the values of their medical parameters changed less than 5% due to compression, which indicates reliable results.

Algorithms↗
PubMed2004

Electronic medical record systems in Israel's public hospitals.

BACKGROUND: Various medical centers in Israel have recently incorporated electronic medical record systems. Knowing the EMR systems' features and pattern of use is an essential step for developing locally and nationally integrated systems. OBJECTIVES: To evaluate the status of EMR systems in all major general hospitals in Israel in terms of the applications used and the patterns of use. METHODS: Structured questionnaires were sent to hospital directors and directors of medical informatics units of 26 general and pediatric hospitals serving the vast majority of the population in Israel. The questionnaire included questions pertaining to the EMR systems, their usage, and the attitude of the participants to data security issues. RESULTS: Of the 26 general hospitals 23 (88.4%) returned the questionnaires. Of these, 21 (91.3%) use EMR systems. Twenty-seven different types of systems are in use in Israeli hospitals, and generally more than one type is used in a hospital. Physicians work with EMR systems in over 98% of the departments. Also, the EMR systems are used for clinical admission and discharge in over 90% of the departments and for medical daily follow-up in about 45%. CONCLUSIONS: Most of the hospitals in Israel use EMR systems but there is no standard data model. Physicians are the main users but the amount of data entered is still limited. Adoption of standards is essential for the integration of electronic patient records across Israeli healthcare organizations.

Adolescent↗
PubMed2004

Brainstorming about next-generation computer-based documentation: an AMIA clinical working group survey.

UNLABELLED: Computer-based software to record histories, physical exams, and progress or procedure notes, known as computer-based documentation (CBD) software, has been touted as an important addition to the electronic health record. The functionality of CBD systems has remained static over the past 30 years, which may have contributed to the limited adoption of these tools. Early users of this technology, who have tried multiple products, may have insight into important features to be considered in next-generation CBD systems. OBJECTIVE AND METHODS: We conducted a cross-sectional, observational study of the clinical working group membership of the American Medical Informatics Association (AMIA) to generate a set of features that might improve adoption of next-generation systems. The study was conducted online over a 4-month period; 57% of the working group members completed the survey. RESULTS: As anticipated, CBD tool use was higher (53%) in this population than in the US physician offices. The most common methods of data entry employed keyboard and mouse, with agreement that these modalities worked well. Many respondents had experience with pre-printed data collection forms before interacting with a CBD system. Respondents noted that CBD improved their ability to document large amounts of information, allowed timely sharing of information, enhanced patient care, and enhanced medical information with other clinicians (all P < 0.001). Respondents also noted some important but absent features in CBD, including the ability to add images, get help, and generate billing information. CONCLUSIONS: The latest generation of CBD systems is being used successfully by early adopters, who find that these tools confer many advantages over the approaches to documentation that they replaced. These users provide insights that may improve successive generations of CBD tools. Additional surveys of CBD non-users and failed adopters will be necessary to provide other useful insights that can address barriers to the adoption of CBD by less computer literate physicians.

Adult↗
PubMedDate not supplied

Internet as clinical information system: application development using the World Wide Web.

Clinical computing application development at Columbia-Presbyterian Medical Center has been limited by the lack of a flexible programming environment that supports multiple client user platforms. The World Wide Web offers a potential solution, with its multifunction servers, multiplatform clients, and use of standard protocols for displaying information. The authors are now using the Web, coupled with their own local clinical data server and vocabulary server, to carry out rapid prototype development of clinical information systems. They have developed one such prototype system that can be run on most popular computing platforms from anywhere on the Internet. The Web paradigm allows easy integration of clinical information with other local and Internet-based information sources. The Web also simplifies many aspects of application design; for example, it includes facilities for the use of encryption to meet the authors' security and confidentiality requirements. The prototype currently runs on only the Web server in the Department of Medical Informatics at Columbia University, but it could be run on other Web servers that access the authors' clinical data and vocabulary servers. It could also be adapted to access clinical information from other systems with similar server capabilities. This approach may be adaptable for use in developing institution-independent standards for data and application sharing.

Computer Communication Networks↗
PubMed2000

Implementing an ICU-CIS integrated to a HIS in Latin America.

The hospital has been the main target for Medical Informatics since the beginning of its development. Ancillary and clinical systems entered into the scene first when the financial issues were covered. From those kind of applications the Intensive Care Unit (ICU) represents perhaps the most important challenge to achieve where there is a representative subset of the organization with most variables under control to show the performance of the institution. At the ICU, information technology defines many of the tasks which are performed and enable the professionals to process and interpret the great quantities of data that is generated about the patients and the system in which they receive their treatment and quality assurance (QA) is now almost completely dependent upon information technology in pretty much facets of medical care. In this paper, a clinical information system developed for the ICU is presented where the use of validated severity illness scoring systems and standardized definitions for events and outcomes the care delivered can be analysed comparing clinical outcomes and resource utilization. Cost containment can be also applied and observations simultaneously with quality improvement standards can be undergone. Clinical research regarding medical and nursing practice is also very helpful.

Hospital Information Systems↗
PubMed1999

Medcast: evaluation of an intelligent pull technology to support the information needs of physicians.

This study reports the initial results of an evaluation of Medcast, a commercial medical information service that uses intelligent pull technology to deliver medical information to practicing physicians. Medical news, CME, and other information are transferred by modem nightly to the physician's computers where this information can be accessed at a convenient time. A survey was faxed to 195 subscribers to the system. A total of 73 (39%) responded. The results indicate that prior to implementation of the Medcast system, almost 40 percent of the respondents did not use their computers for professional activities because of time constraints, costs and computer literacy problems. After implementation of Medcast, almost 70 percent of the respondents used the system two or more hours per week. Ninety percent of the respondents felt that use of the system has enhanced their practice. These findings have important implications for future efforts to implement medical informatics applications to support the information needs of practicing physicians. Experience with intelligent pull technology that is relatively easy to use may be a good way to break down attitudes and barriers to the use of computer systems to support clinical practice and may prepare physicians for a wider use of the Internet to support their future information needs.

Alabama↗
PubMed1997

Galen-In-Use: an EU Project applied to the development of a new national coding system for surgical procedures: NCAM.

GALEN has developed a language independent common reference model based on a medically oriented ontology and practical tools and techniques for managing healthcare terminology including natural language processing. GALEN-IN-USE is the current phase which applied the modelling and the tools to the development or the updating of coding systems for surgical procedures in different national coding centre co-operating within the European Federation of Coding Centre (EFCC) to create a multilingual knowledge repository for multicultural Europe. NCAM (Nomenclature Commune des Actes Médicaux) is the new French multipurpose coding system for surgical procedures. The labels are processed from the intermediate dissections to the Grail representation and the natural language generation by the electronically related Medical Informatics research centres network of Saint Etienne, Manchester, Geneva and Nijmegen. The national coding centre is able to retrieve the initial labels with different categories of concepts, to compare the professional language proposed by expert clinicians to the French generated controlled vocabulary and to finalize the linguistic labels of the coding system in relation with the meanings of the conceptual system structure.

Electronic Data Processing↗
PubMed1993

Computerized medical records. Dream or reality?

For over 25 years many clinicians and others working in health-related fields have envisioned the day when physicians will use a computer on their desk or at the bedside to enter and retrieve the medical records and other information needed to care for their patients. Pioneers in medical informatics have been working during this time to develop the concepts and systems to make this possible, but so far, with only a few exceptions, this has been still mostly a dream. However, we may now be on the threshold of the time when these systems will be implemented on a large scale and become an integral part of the practice of clinical medicine, making the vision no longer a dream but a reality.

Humans↗
PubMedDate not supplied

The tyranny of the diagnosis code.

The electronic medical record (EMR), while having acknowledged advantages over the paper record and powerful constituencies advocating its adoption, is not in widespread use. One significant obstacle to its acceptance by physicians has not been addressed--its failure to provide easy input for the patients exact diagnoses and for the retrieval of those diagnoses during subsequent patient care. Furthermore, our system designers have failed to respond to the expansion of the use of the medical record from its origin as simply the physician's memory and communication tool to becoming the building block for our Medical Record Health Information System (MRHIS), where it also supplies the justification for payment for care and is the source of fundamental statistics about health and healthcare. These problems reflect a basic flaw in the application of available information technology to EMR design and data management: We use output codes--the category codes from ICD-9-CM--for input of diagnoses. This fact imposes the tyranny. Our medical record must have these ICD-9-CM codes for the reimbursement system. But, to be accepted as the basic record for medical care, and at the same time, to be truly useful for case retrieval and statistics, medical informatics experts recognize that our EMR must have codes for the exact diagnoses of the patient (diagnosis entities). But no practical method for their input and management has been offered This paper proposes a way to provide easy input of diagnosis entities, and their permanent coding as a workable solution to the problem.

Abstracting and Indexing↗
PubMedDate not supplied

[Education in public health in Mauritius. Presentation of an experience].

In December 1991, fourteen physicians in the public sector received a degree entitled "Methods in public health", awarded by the dean of Université de Bordeaux II (France) and the Mauritius minister of health. The ceremony crowned a two-year course consisting of 350 hours of lectures and other teaching exercises, broken down into 12 subject areas (epidemiology, biostatistics, medical informatics, demographics, health care, planning, health economics, etc.). The graduates did an average of 10 year's field work in a primary health care center. The degree was awarded after completion of a mini-thesis based on an original study of a selected Mauritian public health problem. In 1992 and 1993, a new, shorter course in community health was offered to other Mauritian physicians by staff from Université de Bordeaux II. We consider that such initiatives would be profitable in other countries like Mauritius, where commonly encountered health care problems of the developing countries coexist with those found in the industrialized world. This will also be an important initiative in countries where initial training in various contexts and therefore can benefit from a common continuing medical education, particularly in public health. One key factor in the success of such projects is their full integration within the medical sciences.

Curriculum↗
PubMed2002

Electronic patient record for N.N. Burdenko Neurosurgical Institute: on the road to paperless patient record.

The paper is devoted to one of a number of highways of medical informatics: a road from traditional paper patient record (PPR) to future paperless patient record (PLPR). This road runs via modem electronic patient record (EPR), usually blending together electronic and paper technologies of gathering, storing, retrieving, presentation and legalization of data. The following is based on the experience of modelling, engineering, deployment, support and evolution of electronic patient record for N.N. Burdenko neurosurgical institute. Three basic facets of the problem will be discussed: technological, psychological and legal.

Medical Records Systems, Computerized↗