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At least 1,189 records · Page 66Linked to original sources
PubMed2002

Evidence-based management: using serial firm trials to improve diabetes care quality.

BACKGROUND: The design of delivery systems that can truly conduct continuous quality improvement (CQI) as a routine part of clinical care provision remains a vexing problem. The effectiveness of the "computerized firm system" approach to chronic disease CQI was examined, with diabetes as the focus of a 5-year case study. METHODS: A large family medical center had been divided into two parallel group practices for reasons of efficiency. These frontline structures (also known as primary care "firms") were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups. Because all the required longitudinal data were contained in a computerized repository, it was possible to conduct these controlled "firm trials" in a matter of months at low cost. RESULTS: During a 3-year period, implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin (HbA1c) testing by 50% (p = 0.02) and reduced the number of diabetic patients inadequately controlled by 43% (p < 0.01). Following this outcome improvement, patients exhibited a 16% reduction in ambulatory visit rates (p = 0.04). The observed outcome improvement, however, was reversed during the subsequent 2 years, when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions. CONCLUSIONS: The processes and outcomes of diabetes care were improved, demonstrating that CQI and controlled trials are not mutually exclusive in moving toward the practice of evidence-based management. Health care systems can, by conducting serial firm trials, become learning organizations. CQI programs of all kinds will likely never flourish, however, until quality improvement and reimbursement mechanisms have become better aligned.

Adult↗
PubMed2003

Teaching evidence-based medicine to surgical subspecialty residents.

BACKGROUND: Curricula for the teaching of evidence-based medicine to residents have been the subject of reports, analyses, and commentary. Specific programs for teaching evidence-based medicine principles to surgical subspecialty residents have not been identified by the authors. The objective of this article is to report our experience in establishing a teaching program in the principles of evidence-based medicine to surgical subspecialty residents. STUDY DESIGN: We established a teaching program in the principles of evidence-based medicine for neurosurgical residents in a busy neurosurgical training program. Two hours were set aside every other week, replacing traditional professors' rounds with sessions led jointly by a neurosurgeon and an epidemiologist, but based on case presentations from patients currently being treated. From these presentations, searchable clinical questions were developed, and the literature was searched, critically analyzed, and summarized. Results of several cycles on this process are reported. RESULTS: The group developed a repository of Internet-based resources for evidence-based education and practice. Using these resources, the group analyzed six topics in the first 2 years of the program. These included the "best" way to clinically grade patients after subarachnoid hemmorhage, considerations in the biopsy and treatment of enhancing intracerebral mass lesions in patients with acquired immunodeficiency syndrome, the use of prophylactic anticonvulsants in patients with primary brain tumors, the identification of cervical spine injuries in the emergency department, the grading of the fractures of the odontoid process, and the value of removing retained bullets from the spinal canal. The outcomes ranged from finding insufficient evidence to reach a conclusion, through the identification of well-conducted and well-reported critical syntheses of the topic already available in literature, to the development of the detailed algorithm for cervical spine clearance that was accepted by the institution's emergency department. CONCLUSIONS: By dedicating some specific time and using resources readily available in most academic health centers, it is possible to incorporate the teaching of the principles of evidence-based practice into the ongoing education of residents on a busy surgical subspecialty service.

Curriculum↗
PubMed2001

MHC class I molecules can direct proteolytic cleavage of antigenic precursors in the endoplasmic reticulum.

The large set of peptides presented by MHC (major histocompatibility complex) class I molecules are generated by proteolysis of diverse precursors in the cytoplasm and possibly in the endoplasmic reticulum (ER). To define the potential peptide trimming events in the ER, we analyzed proteolytic products generated in isolated microsomes. The residues flanking the N terminus of the final antigenic peptide were rapidly removed within the microsomes but only in the presence of appropriate MHC molecules. Remarkably, the precursor peptide was bound to the MHC molecules in a distinct conformation and required an aminopeptidase activity to generate the optimal peptide. The MHC molecules are therefore not only the final repositories of antigenic peptides, but they can also direct their excision from longer precursors.

Aminopeptidases↗
PubMedDate not supplied

Development of the Crash Injury Research and Engineering Network.

The Crash Injury Research and Engineering Network has developed a computer database and wide area network for data sharing and analysis among 8 trauma centers. The computer database extends the National Highway Traffic Safety Administration's National Automotive Sampling System with medical- and trauma-related variables in a relational/object database system. The medical data include injury location details, injury subclassification systems, and medical images for better biomechanical injury evaluation. Key data elements are migrated to a core repository so that all centers can review the status of case acquisition across the network. Cases, whole or in part, may be migrated between centers so that individual center expertise may be shared in evaluating the cause of injury. Electronic rounds, where cases are reviewed simultaneously across multiple centers, are possible.

Accidents, Traffic↗
PubMed2000

Passive dispersion of latex aeroallergen in a healthcare facility.

BACKGROUND: Prompted by worsening asthma in a dental assistant with latex allergy and occupational asthma while under personal latex precautions, we confirmed continuing latex aeroallergen exposure. OBJECTIVES: To determine the source of latex aeroallergen and ascertain the effects of site-wide substitution of nonpowdered low allergen latex glove in a health care site. METHODS: Using a volumetric sampler, baseline latex aeroallergen levels were measured in rooms where she worked and nearby rooms, as well as shared X-ray, laboratory, and waiting rooms. Allergen levels were measured in upholstery fabric samples, ventilation duct dust, and latex gloves. Alterations in aeroallergen levels following change of glove types were prospectively determined. RESULTS: Baseline latex aeroallergen levels ranged from 6 to 25 ng/m3 in the patient's work areas and in other rooms from 29 to 90 ng/m3 during work hours. Latex antigen was found in three brands of powdered latex gloves (chi = 1,156 microg/g) used in the nearby opertories and the hygiene room, and in upholstery fabric, carpet dust, but not ventilation duct dust. In the absence of any other control measures, airborne latex became undetectable (<5 ng/m3) with exclusive use of nonpowdered latex gloves. DISCUSSION: Latex aeroallergen is primarily generated by active glove use; carpeting and fabric upholstery can serve as important aeroallergen repositories. Site-wide substitution of nonpowdered latex gloves eliminates detectable latex aeroallergen.

Air Pollutants, Occupational↗
PubMed2000

Case studies in pathology from the National Museum of Health and Medicine, Armed Forces Institute of Pathology.

The National Museum of Health and Medicine was founded as the Army Medical Museum during the American Civil War to document the effects of war wounds and disease on the human body. Since then, the Museum has created a collection of documented pathologic specimens that can be used to study the gross and microscopic appearance of disease conditions. The Museum's collections are a vital link to the past and the future of medical research and form a unique national medical repository that is used continuously for research, education, and exhibit purposes. Today, the Museum in association with its parent institution, the Armed Forces Institute of Pathology, provides access to over 130 years of documented medical specimens. These specimens allow the unique opportunity to re-examine historical classification systems and disease diagnoses. The case of subacute chronic osteomyelitis with cortical sequestration of Private J. Potter from the Civil War is presented here.

Amputation, Surgical↗
PubMed2001

Molecular epidemiology of tuberculosis among eight hospitals in New York City, 1996-1997.

OBJECTIVE: To determine the molecular epidemiology of tuberculosis isolated from patients cared for at eight hospitals scattered throughout New York City. MATERIALS AND METHODS: Cases of tuberculosis occurring in 1996 and 1997 at collaborating hospitals were identified, and demographic data were extracted from patient charts. All available isolates were analyzed by IS6110 for genetic relatedness. The molecular fingerprints were compared both to each other and to the larger repository of strains from New York City developed and maintained at the Public Health Research Institute. RESULTS: One hundred and eighty cases were fully characterized. Compared with New York City cases, study patients were more likely to be Asian and less likely to be non-Hispanic blacks. Overall, 97 (54%) of the cases were clustered with respect to other study strains or with respect to the other New York City isolates. Clustered strains were significantly more likely to be from non-Hispanic blacks or patients born in the United States. The largest cluster (n = 17) was the "W" strain previously associated with an outbreak of multidrug-resistant tuberculosis in New York City. In the current study, the majority of W strain isolates were fully drug-susceptible. CONCLUSIONS: High rates of genetically related tuberculosis continue to occur among patients in New York City, in spite of improved control of nosocomial outbreaks and dramatic decreases in the overall case rates. The use of molecular techniques to suggest patterns of transmission has become essential in developing and assessing routine tuberculosis control strategies.

Adult↗
PubMed2003

Asian online Y-STR Haplotype Reference Database.

For several years Y-chromosomal microsatellites (short tandem repeats, STRs) have been well established in forensic practice. In this context, the genetic characteristics of the Y chromosome (i.e. its paternal inheritance and lack of recombination) render STRs particularly powerful. However, genetic differences between male populations appear to be larger for Y-STRs than for autosomal STRs, a fact that is most likely due to the higher sensitivity of Y-chromosomal lineages to genetic drift (Forensic Sci Int 118 (2001) 153). The assessment of probabilities for matches between haplotyped male persons or traces/persons requires the typing of a large number of haplotypes in the appropriate reference populations. The haplotype data of a large number of European as well as South and North American populations have been collected and are continuously published online (Y-STR Haplotype Reference Database--YHRD; http://www.ystr.org). The most recent multicentric effort has led to the establishment of an Asian YHRD (http://www.ystr.org/asia) which has been available since January 2002. All databases are maintained and curated at the Institute of Legal Medicine, Humboldt-University, Berlin and will soon be fused to a global repository including populations from all continents.

Asia↗
PubMed2003

Domains, motifs and clusters in the protein universe.

The rapid growth of bio-sequence information has resulted in an increasing demand for reliable methods that group proteins. A few databases with curated alignments of protein families have demonstrated that expert-driven repositories can keep up with the data deluge in the genome era. These original resources implicitly identify domain-like modules in proteins. An increasing number of automatic methods have sprouted over the past few years that cluster the protein universe. Many of these implicitly dissect proteins into structural domain-like fragments. In a very coarse-grained evaluation, some of the automatic methods appear to be on par with expert-driven approaches. However, neither automatic nor manual methods are currently entirely up to the challenges of tasks such as target selection in structural genomics. Thus, we urgently need refined and sustained automatic clustering tools.

Amino Acid Motifs↗
PubMed2000

GALEN: a third generation terminology tool to support a multipurpose national coding system for surgical procedures.

Generalised architecture for languages, encyclopedia and nomenclatures in medicine (GALEN) has developed a new generation of terminology tools based on a language independent model describing the semantics and allowing computer processing and multiple reuses as well as natural language understanding systems applications to facilitate the sharing and maintaining of consistent medical knowledge. During the European Union 4 Th. framework program project GALEN-IN-USE and later on within two contracts with the national health authorities we applied the modelling and the tools to the development of a new multipurpose coding system for surgical procedures named CCAM in a minority language country, France. On one hand, we contributed to a language independent knowledge repository and multilingual semantic dictionaries for multicultural Europe. On the other hand, we support the traditional process for creating a new coding system in medicine which is very much labour consuming by artificial intelligence tools using a medically oriented recursive ontology and natural language processing. We used an integrated software named CLAW (for classification workbench) to process French professional medical language rubrics produced by the national colleges of surgeons domain experts into intermediate dissections and to the Grail reference ontology model representation. From this language independent concept model representation, on one hand, we generate with the LNAT natural language generator controlled French natural language to support the finalization of the linguistic labels (first generation) in relation with the meanings of the conceptual system structure. On the other hand, the Claw classification manager proves to be very powerful to retrieve the initial domain experts rubrics list with different categories of concepts (second generation) within a semantic structured representation (third generation) bridge to the electronic patient record detailed terminology.

Abstracting and Indexing↗
PubMed2000

Evaluation of a data warehouse in an academic health sciences center.

OBJECTIVES: The Clinical data repository (CDR) at the University of Virginia Health System is a data warehouse that provides direct access to data for clinical research and effective decision making. We undertook an evaluation of the CDR to understand factors affecting its adoption. DESIGN: We used a theoretical framework that is based on diffusion of innovation theory. Building on validated survey instruments, we developed a questionnaire and conducted interviews of key executive leaders. Fifty-three individuals with logon ids to the CDR completed our questionnaire. Twelve executive leaders were interviewed. MEASUREMENTS: The outcome variables were the initial and continued use of the CDR. Independent variables included attributes suggested by diffusion theory (i.e. relative advantage, complexity), knowledge and skills expected to correlate with computer usage, and the influence of communication channels. RESULTS: Our overall response rate was 82%. We identified characteristics of users associated with the initial decision to use the CDR. Compatibility with an individual's skills and work style was associated strongly with satisfaction and continued use. Secondly, the importance of organizational culture and the need for data was illuminated by management interviews. CONCLUSIONS: We have shown that diffusion of innovation theory can be used to help understand factors contributing to the success of a data warehouse in a healthcare setting. Our results suggest areas for future research and inquiry as the CDR evolves.

Academic Medical Centers↗
PubMed2001

Medical informatics--the state of the art in the Hospital Authority.

Since its inception in 1990, the Hospital Authority (HA) has strongly supported the development and implementation of information systems both to improve the delivery of care and to make better information available to managers. This paper summarizes the progress to date and discusses current and future developments. Following the first two phases of the HA information technology strategy the basic infrastructural elements were laid in place. These included the foundation administrative and financial systems and databases; establishment of a wide area network linking all hospitals and clinics together; laboratory, radiology and pharmacy systems with access to results in the ward. A major push into clinical systems began in 1994 with the clinical management system (CMS), which established a clinical workstation for use in both ward and ambulatory settings. The CMS is now running at all major hospitals, and provides single logon access to almost all the electronically collected clinical data in the HA. The next phase of development is focussed on further support for clinical activities in the CMS. Key elements include the longitudinal electronic patient record (ePR), clinical order entry, generic support for clinical reports, broadening the scope to include allied health and the rehabilitative phase, clinical decision support, an improved clinical documentation framework, sharing of clinical information with other health care providers and a comprehensive data repository for analysis and reporting purposes.

China↗
PubMed2001

The retrieval effectiveness of medical information on the web.

The World Wide Web has become such an extensive health information repository in the world that it is increasingly difficult to search for relevant medical information. Many search tools have been developed to help users look for relevant health information on the web, but most of them are still not efficient. In this paper, we discuss some available on-line solutions to medical information retrieval and compare the performances of some general and medicine-specific search engines with the MediAgent, which has been developed by the National University of Singapore (NUS) Medical Informatics Programme. Although a number of medicine-specific searching techniques have been developed, the difficulty of finding medical information still remains because medical search engines are generally not as effective as generic search engines. Different from other search tools, MediAgent's efficiency was quite high, taking only an average of 1.5 links to retrieve the answers, but its retrieving effectiveness is not good enough due to the short period of operation. Whilst the MediAgent project cannot claim to have all the solutions, it nevertheless offers a new alternative to system implementation. New techniques need to be explored in order to overcome the issues of medical information retrieval on the Internet.

Humans↗
PubMed2001

Clinical websites are currently dangerous to health.

The Internet is becoming a ubiquitous medium, open to all. The paper explores the reasons why current health-related websites require extensive review and investment to ensure that they address the full spectrum of the audiences who may access their site. The audiences are no longer purely local or even solely those who work in the health domain. They will include everyone, from professional healthcare practitioners to members of the general public. The site web masters should also consider the range of purposes for which these disparate groups access the site. The language, content intensity and presentation should have a different style and be identified by its intended audience to avoid a range of problems including mis-interpretation, mis-targetting of content, mis-representation of source and quality. Inappropriate content and presentation could jeopardise the credibility of health sites, and thus healthcare provision, with the newly emerging audiences. Recent studies involving the evaluation of many web sites have assessed their 'fitness for purpose' as information repositories for different audiences. The criteria by which clinically related web contents are judged will vary, depending on the type of visitor to the site. Formal qualification of web content is ongoing--addressing both structured definition [1] and quality criteria [2]. Originators of web material should consider the full spectrum of the audiences who may access their site, from professional healthcare practitioners to members of the general public, and the purposes for which they access the site. The language, content intensity and presentation should have a different style and be identified by its intended audience to avoid a range of problems including mis-interpretation, mis-targetting of content, mis-representation of source and quality.

Health↗
PubMed2001

Knowledge management in healthcare: towards 'knowledge-driven' decision-support services.

In this paper, we highlight the involvement of Knowledge Management in a healthcare enterprise. We argue that the 'knowledge quotient' of a healthcare enterprise can be enhanced by procuring diverse facets of knowledge from the seemingly placid healthcare data repositories, and subsequently operationalising the procured knowledge to derive a suite of Strategic Healthcare Decision-Support Services that can impact strategic decision-making, planning and management of the healthcare enterprise. In this paper, we firstly present a reference Knowledge Management environment-a Healthcare Enterprise Memory-with the functionality to acquire, share and operationalise the various modalities of healthcare knowledge. Next, we present the functional and architectural specification of a Strategic Healthcare Decision-Support Services Info-structure, which effectuates a synergy between knowledge procurement (vis-à-vis Data Mining) and knowledge operationalisation (vis-à-vis Knowledge Management) techniques to generate a suite of strategic knowledge-driven decision-support services. In conclusion, we argue that the proposed Healthcare Enterprise Memory is an attempt to rethink the possible sources of leverage to improve healthcare delivery, hereby providing a valuable strategic planning and management resource to healthcare policy makers.

Clinical Competence↗
PubMed2002

The patient clinical information system (PatCIS): technical solutions for and experience with giving patients access to their electronic medical records.

As health records evolve into electronic form, increasing demand is being made to provide patients with access to them. We sought to study the character and impact of such access to determine how patients use such records, what cognitive effects it has on them, and how it affects their relationship with their health care providers. We created the Patient Clinical Information System (PatCIS) to interface with the clinical data repository at New York Presbyterian Hospital (NYPH) to allow patients to add to and review their medical data. We also provided educational resources and automated advice programs. We provided access to the system to thirteen subjects over a 36-month period and reviewed their activities in the system's usage log. We also collected data via questionnaire and telephone interview. We collected data for a total of 223 patient months. We found that patients varied in their use of the system, from once a month or less to one or more times per day. All patients primarily used the system to review laboratory results. Both they and their physicians believed that use of the system enhanced the patients' understanding of their conditions and improved their communication with their physicians. There were no adverse events encountered during the study.

Adult↗
PubMed2002

Leveraging XML-based electronic medical records to extract experiential clinical knowledge. An automated approach to generate cases for medical case-based reasoning systems.

Case-based reasoning (CBR)-driven medical diagnostic systems demand a critical mass of up-to-date diagnostic-quality cases that depict the problem-solving methodology of medical experts. In practical terms, procurement of CBR-compliant cases is quite challenging, as this requires medical experts to map their experiential knowledge to an unfamiliar computational formalism. In this paper, we propose a novel medical knowledge acquisition approach that leverages routinely generated electronic medical records (EMRs) as an alternate source for CBR-compliant cases. We present a methodology to autonomously transform XML-based EMR to specialized CBR-compliant cases for CBR-driven medical diagnostic systems. Our multi-stage methodology features: (a) collection of heterogeneous EMR from Internet-accessible EMR repositories via intelligent agents, (b) automated transformation of both the structure and content of generic EMR to specialized CBR-compliant cases, and (c) inductive estimation of the weight of each case-defining attribute. The computational implementation of our methodology is presented as case acquisition and transcription info-structure (CATI).

Artificial Intelligence↗
PubMed2003

Health care quality management by means of an incident report system and an electronic patient record system.

BACKGROUND: Quality management in health care services has not been as successful as in other industries. OBJECTIVE: To assess the potential contribution of an on-line incident reporting system (OIRS) and of an electronic patient record (EPR) system to quality management in hospitals. METHODS: The two approaches are being implemented in Osaka University Hospital. RESULTS: Analysis of the early use of the on-line reporting system indicates that this qualitative approach has been effective to avoid adverse medical events. The quantitative methodology with the EPR is still in the phase of developing. CONCLUSION: Direct data entry by medical staff and an EPR based on dynamic templates and a dynamic problem oriented approach could be useful for building clinical data repositories that can support clinical quality management.

Humans↗