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PubMed1995

The SAPPHIRE toolkit: an interactive system for the evaluation of primary healthcare computing.

Since April 1992, the SAPPHIRE Project (Systems Accreditation Project in Primary Healthcare Informatics Requirements and Evaluations) has been funded by the Department of Health in the United Kingdom with the goal of providing a framework for the fair and objective evaluation of General Medical Practice (GMP) computer systems [1]. SAPPHIRE is comprised of three 'facets': A comprehensive specification list for GMP information systems. An Assessment methodology to apply the SAPPHIRE specifications. The Integrated Toolkit. The SAPPHIRE Integrated Toolkit has been developed as an interactive computer-based guide for use in the processes of GMP system procurement and education. By integrating the two other 'facets' of SAPPHIRE, it provides a means of matching a set of user-defined specifications against the systems under consideration. This is achieved by enabling the Toolkit user to interactively weight the presented SAPPHIRE specifications to their individual requirements and then match this weighted specification against a database of benchtest results for available systems. The output from this matching process then gives the range of systems which most clearly meet that particular user's needs as well as highlighting the areas where systems fail to meet their defined requirements. Since the SAPPHIRE specification list is a lengthy document comprised of technical language, the Toolkit uses a range of browsing models to display the specifications in accessible ways to the end-user. These browsing models present the specifications in contexts that are familiar to the everyday experience of healthcare employees and hence are easy to access and understand. In addition, the Toolkit offers a 'Quick Route Questionnaire' which accesses a shortcut to the matching process described above. his presentation will demonstrate the main functions of the Toolkit and outline specific scenarios of use. Another area of discussion will be the approach of the SAPPHIRE Project to the problems and issues of computer system evaluation, with reference to the Toolkit in a communications context, assisting in the transfer of understanding between the technical language of system designers and suppliers and the healthcare professional, who may lack computer expertise [2]. The SAPPHIRE Toolkit has a wide range of applications for facilitating the procurement of, and the education processes entailed in, primary healthcare computing. We view the Toolkit as a potential benefit to many aspects of the healthcare profession, including General Practice, Surgery, Healthcare IT Administration, and Information System Supply and Management.

Ambulatory Care Information Systems↗
PubMed1995

Data capture workstations, scanned forms, and pen-based systems for clinician use.

Data capture is the most difficult aspect of creating an automated medical record. The U.S. Department of Veterans Affairs (V.A.) is developing, testing and evaluating the benefits of a number of data capture technologies, including physician's workstations, scanned forms, and pen-based system as an aid to medical data capture in the outpatient clinic environment. The software being used for physician data entry, which supports a variety of data capture devices, will be demonstrated.

Computer Peripherals↗
PubMed1995

Computer-assisted trauma care prototype.

Each year, civilian accidental injury results in 150,000 deaths and 400,000 permanent disabilities in the United States alone. The timely creation of and access to dynamically updated trauma patient information at the point of injury is critical to improving the state of care. Such information is often non-existent, incomplete, or inaccurate, resulting in less than adequate treatment by medics and the loss of precious time by medical personnel at the hospital or battalion aid station as they attempt to reassess and treat the patient. The Trauma Care Information Management System (TCIMS) is a prototype system for facilitating information flow and patient processing decisions in the difficult circumstances of civilian and military trauma care activities. The program is jointly supported by the United States Advanced Research Projects Agency (ARPA) and a consortium of universities, medical centers, and private companies. The authors' focus has been the human-computer interface for the system. We are attempting to make TCIMS powerful in the functions it delivers to its users in the field while also making it easy to understand and operate. To develop such a usable system, an approach known as user-centered design is being followed. Medical personnel themselves are collaborating with the authors in its needs analysis, design, and evaluation. Specifically, the prototype being demonstrated was designed through observation of actual civilian trauma care episodes, military trauma care exercises onboard a hospital ship, interviews with civilian and military trauma care providers, repeated evaluation of evolving prototypes by potential users, and study of the literature on trauma care and human factors engineering. This presentation at MedInfo '95 is still another avenue for soliciting guidance from medical information system experts and users. The outcome of this process is a system that provides the functions trauma care personnel desire in a manner that can be easily and accurately used in urban, rural, and military field settings. his demonstration will focus on the user interfaces for the hand-held computer device included in TCIMS, the Field Medic Associate (FMA). The FMA prototype is a ruggedized, water-resistant personal computer, weighing approximately 5 lbs. It has an LCD graphical user interface display for patient record input and output, pen-based and audio input, audio output, and wireless communications capabilities. Automatic recording and dynamic, graphical display of time-stamped trends in patient vital signs will be simulated during the demonstration. Means for accessing existing patient record information (e.g., allergies to particular medications) and updating the record with the nature of the injury, its cause, and the treatments that were administered will be shown. These will include use of an electronic pen to mark up anatoglyphs (standard drawings of human body appearing on computer screen) to show where injuries occurred and where treatments were applied, and to input textual descriptions of the nature of the injury, its cause, what treatments were administered, etc. Computer recognition of handwritten inputs will be shown. Likewise, voice annotation and audio playback of patient record information by medics and hospital personnel will be illustrated. These latter technologies free the care providers' hands to treat the patient; they can therefore provide inputs to the patient record while information is fresh in their minds. The audio playback option allows hospital personnel to select more detailed voice annotations of specific portions of the patient record by simply touching the electronic pen to a particular place where an electronic pen marking was made by a medic in the field and then listening to the medic's corresponding audio commentary. Finally, the FMA's means for assisting the medic in simultaneously managing several injured patients will be shown. (abstract truncated)

Emergency Medical Services↗
PubMed1995

A Windows-based tool for the study of clinical decision-making.

Studies of health-provider decision-making, and of their practice patterns, play a central role in efforts to improve the quality and effectiveness of care and in decreasing costs of healthcare delivery systems. Researchers from a variety of disciplines have studied a broad range of clinical conditions, using a number of methodological approaches and measurement tools, including self-report, written clinical vignettes, simulated clinical encounters using actors as patients and analysis of medical records and administrative data. Although these provide information about the outcomes of clinical decisions, they provide little or no information about the process of the decision. Most clinicians agree that the decision process is as important as the outcome, and indeed it is not unusual to have an exemplary process but a poor outcome. Process information is therefore a crucial dimension of care evaluation. In this paper, we describe a new software product that was originally used to measure diagnostic reasoning in the basic medical science of immunology; subsequently adapted to measure key steps in the clinical decision-making process. This Windows-based software is user-friendly, inexpensive, and requires only commonly available hardware for its operation. It is very flexible, permitting the creation of unlimited numbers and types of clinical scenarios, with diagnostic and/or management approaches. Being clinically "real-world," the scenarios are familiar to the user, who is therefore likely to respond in a "real-world" fashion, with the consequent improved accuracy of data. In addition, a wide range of users may be accommodated. The clinical activities of physicians, nurses, pharmacists, and any other clinical providers may be measured and analyzed by the system. Non-clinical providers, such as managers and administrators, could also be assessed. The system has three major modes. In the Authoring Mode, the author creates a menu, which is common to a number of linked scenarios. For example, the menu for physicians might include the History, Physical examination, Laboratory tests, Radiology, Consultations, etc. The actual details of each related clinical case may then be varied. There is virtually unlimited flexibility in the design of the menu and the clinical details, depending on the needs of the author, and the type of information desired. Both diagnostic and management scenarios are easily constructed. The cost for each individual step may be assigned, using any scoring scale desired. Actual dollar costs, or a suitable point score, are equally possible. Once the menu and associated scenarios are generated, the candidate is asked to solve the clinical problem in the User Mode. The candidate obtains information by "mouse-clicking," so it is not necessary to be a computer expert to use the system. Eventually, the candidate is presented with a short vignette outlining the desired solution, which may include the authors comments, sources for further information, etc. In the Data Collection and Analysis Mode, the candidate proceeds to solve the scenario, the software captures and stores each individual information request i.e., each step in the candidates reasoning process. Thus, the reasoning process can be examined, including timing and order and types of information used; this may be done both for individual candidates, and also for groups. A "gold standard" reasoning may be predetermined by the author for comparison purposes. The software has already been used to teach immunology to medical students, and is currently being expanded to train gynecology surgeons in the use of Clinical Practice Guidelines. The software has potential applications in many aspects of the healthcare field. For educators, it could serve in traditional exit examinations for the clinical disciplines, both undergraduate and postgraduate. (abstract truncated)

Computer-Assisted Instruction↗
PubMed1995

"Hyperstat": an educational and working tool in epidemiology.

The work of a researcher in epidemiology is based on studying literature, planning studies, gathering data, analyzing data and writing results. Therefore he has need for performing, more or less, simple calculations, the need for consulting or quoting literature, the need for consulting textbooks about certain issues or procedures, and the need for looking at a specific formula. There are no programs conceived as a workstation to assist the different aspects of researcher work in an integrated fashion. A hypertextual system was developed which supports different stages of the epidemiologist's work. It combines database management, statistical analysis or planning, and literature searches. The software was developed on Apple Macintosh by using Hypercard 2.1 as a database and HyperTalk as a programming language. The program is structured in 7 "stacks" or files: Procedures; Statistical Tables; Graphs; References; Text; Formulas; Help. Each stack has its own management system with an automated Table of Contents. Stacks contain "cards" which make up the databases and carry executable programs. The programs are of four kinds: association; statistical procedure; formatting (input/output); database management. The system performs general statistical procedures, procedures applicable to epidemiological studies only (follow-up and case-control), and procedures for clinical trials. All commands are given by clicking the mouse on self-explanatory "buttons". In order to perform calculations, the user only needs to enter the data into the appropriate cells and then click on the selected procedure's button. The system has a hypertextual structure. The user can go from a procedure to other cards following the preferred order of succession and according to built-in associations. The user can access different levels of knowledge or information from any stack he is consulting or operating. From every card, the user can go to a selected procedure to perform statistical calculations, to the reference database management system, to the textbook in which all procedures and issues are discussed in detail, to the database of statistical formulas with automated table of contents, to statistical tables with automated table of contents, or to the help module. he program has a very user-friendly interface and leaves the user free to use the same format he would use on paper. The interface does not require special skills. It reflects the Macintosh philosophy of using windows, buttons and mouse. This allows the user to perform complicated calculations without losing the "feel" of data, weight alternatives, and simulations. This program shares many features in common with hypertexts. It has an underlying network database where the nodes consist of text, graphics, executable procedures, and combinations of these; the nodes in the database correspond to windows on the screen; the links between the nodes in the database are visible as "active" text or icons in the windows; the text is read by following links and opening new windows. The program is especially useful as an educational tool, directed to medical and epidemiology students. The combination of computing capabilities with a textbook and databases of formulas and literature references, makes the program versatile and attractive as a learning tool. The program is also helpful in the work done at the desk, where the researcher examines results, consults literature, explores different analytic approaches, plans new studies, or writes grant proposals or scientific articles.

Computer-Assisted Instruction↗
PubMed1995

A multimedia guide to spinal cord injury: empowerment through self instruction.

The Spinal Cord Injury (SCI) Project is developing a series of instructional modules on SCI that will be distributed via CD-ROM for patient and family education. The modules are based on an instructional program and patient manual distributed by the Paralyzed Veterans of America. The program includes topics ranging from the anatomy and physiology of spinal cord injuries to legal rights established under the Americans With Disabilities Act. The SCI project expands on the instructional manual by combining digital multimedia techniques with motivational features such as games and personal guides. The user selects a personal guide from among a selection of individuals with spinal cord injuries to guide them through tutorials that include accounts of personal experiences. The guides appear in small video windows at various points throughout the tutorials and give personal insight into the topic at hand. The user can also query the other guides to hear their views on a topic. The user interface incorporates 'seamless access' features, which enable persons with a wide range of disabilities to use the program. Innovative features of these modules are the use of personal instructional guides, motivational games and activities, incorporation of alternative input or access strategies, and the use of high quality, low cost, multimedia production strategies.

Audiovisual Aids↗
PubMed1995

New information technologies for healthcare in Aquitaine about the NursePad project.

The first results of a highly successful multidisciplinary NursePad Project in Aquitaine in France are to be presented as a scientific demonstration. A unique data collection system using electronic notepads has reduced the clerical workload of nurses with a further benefit of improved data quality. The system is well accepted by the health professionals using it because the software was designed by them for themselves. It addresses their problems. The developers are anxious to extend their findings into other domains of healthcare, both inside and outside the hospital.

France↗
PubMed1995

Benefits of using hypertext in a health care environment.

This "hyperdemo" shows the development, management, and business benefits of using hypertext in a healthcare environment. The demonstration shows how existing information has been made available in both primary and secondary care; we cover two application areas.

Information Systems↗
PubMed1995

The importance of local data bases in medical expert systems: TICITL.

The database of our medical expert system, TICITL, contains the records of more than 15,000 gastroenterological patients. The data was collected over fifteen years (1977-1992) during which the patients were followed for at least three months to establish a final diagnosis. Using a new set of 230 gastroenterological cases, TICITL's first diagnosis was similar to the final diagnosis in 90% of the patients. When compared to foreign medical expert systems (M.E.S.), there is a considerable difference in diagnostic accuracy favorable to the local system. Another local program is also as accurate as TICITL. Consequently, we attribute these results to the database and strongly recommend employing real local patients whenever possible to implement M.E.S. in a new geographical area.

Databases, Factual↗
PubMed1995

Computerized knowledge bases in primary health care: a curse or a blessing for health promotion, prevention and patient quality?.

This paper presents a future scenario analysis of how the introduction of computerized knowledge bases (KBs) can come to affect primary care practice. For the collection and analysis of data, a two-level video method was applied. First, four consultations where a computerized KB was used were video-recorded. A search workshop was then carried out by letting a multi-disciplinary panel comment on the video recordings. The comments were categorized with regard to content and perspective. Analyses of the comments showed a concern for a disregard of patients' health beliefs and for difficulties in portioning out the acquired medical knowledge to the patient during the consultation. Furthermore, the computerized KB was found to easily break the natural flow of the consultation and be perceived as a third party. The conclusion is that the most critical aspects for using computerized KBs in a reformed primary health care concern the integration of the systems into the consultation process. Health promotion, prevention, and patient quality are central here, and the introduction of KB technology must not lead the consultation away from these issues.

Artificial Intelligence↗
PubMed1995

A computer-assisted case report and diagnosis system: sharing the knowledge database ADM and using hypermedia techniques.

The practice of medicine is characterized by its great variability and by many rare diseases. When the medical students work in hospital units, they must learn the general medical practice in the care of the patient. The purpose of this work was to present a French multifunction decision aid system using artificial intelligence techniques and Hypercard tools for different modules. Through an ergonomic interface, the system assists the user in the construction of medical observations, suggests diagnostic hypothesis, provides documentation and helps the user perform retrieval tasks. The knowledge comes from senior experts and from the pre-existent and large knowledge database, ADM.

Computer Peripherals↗
PubMed1995

User modeling techniques as support in the clinical decision-making process.

This paper describes research work on the design and creation of a medical folder management system capable of establishing co-operative dialogue with users who have access to the information contained therein. The research work has addressed the problem of integrating into the system knowledge about the medical domain and that about users, both necessary to activate co-operative dialogue. The CADMIO [2] prototype has been developed since the study was made. The last version of the CADMIO system stores information about users for the use in recognizing and interpreting their behavior, providing help, and in acquiring and returning further information. Depending on this information the system retrieves and shows the data of the medical folder in an intelligent way by highlighting links between data. It simplifies and increases the speed of the interaction by focusing on the data useful to the decisional activity of the physician.

Bayes Theorem↗
PubMed1995

An integrated system to represent and manage medical knowledge.

This paper describes an integrated system in Prolog that permits the creation of a personal Knowledge Base to express and formalize specialist knowledge in medicine. Formalisms used are production rules and frames. The integrated system is able to manage data and knowledge stored in a database built in M Technology (MUMPS).

AIDS-Related Opportunistic Infections↗
PubMed1995

GAP: a computer-assisted design tool for the development and analysis of evidence-based automated questionnaires.

This paper describes the design and use of a computer-assisted design tool for developing evidence-based automated questionnaires that may assist health practitioners to implement clinical practice guidelines. The Guideline Application Program (GAP) facilitates the design, development, testing, customization, and implementation of interactive patient-computer questionnaires, the analysis of patient-derived information, and the clinical application of practice guidelines that require knowledge of multiple patient-specific characteristics. GAP is being used to create a variety of software applications for HealthQuiz and Microsoft Windows-compatible computers. GAP-generated applications are presently used to support preventive care guideline implementation in primary care settings, preoperative screening in anesthesia clinics, student health screening in Universities, hormone replacement counseling for peri-menopausal women, and patient-reported data collection in various clinical research projects.

Algorithms↗
PubMed1995

Integration of a data dictionary and a clinical database in an expert system for acute abdominal pain.

Despite promising results, computer-aided diagnosis in acute abdominal pain is rarely used in the clinic. We therefore developed an expert system for acute abdominal pain to be used in clinical routine. The system is based on a new approach integrating a data dictionary, a clinical database and the knowledge base. A data dictionary editor has been developed (C++, WINDOWS, IBM-compatible PC) and a data dictionary for acute abdominal pain has been built up. The clinical database has been linked to a documentation program providing three modes of data entry. The documentation program has been evaluated extensively by clinicians. The integrated approach clearly separates clinical data from knowledge, but guarantees high consistency of data.

Abdominal Pain↗
PubMed1995

Description and advantages of an index-driven medical knowledge base.

In the FRAMEMED system design, the inherent attributes of its concepts are expressed in the hierarchical lists of its 26 Elements (e.g., Agents, Clinical Manifestations, Diseases, Tests, etc.). These concepts, contained in regular structures, are then alphabetized by phrase (and synonym), forming a combined index in which the user may quickly find a concept either alphabetically or hierarchically. Stored in the structures of the index are pointers to four types of knowledge records: 1) Descriptive (definition); 2) Relational (incidental attributes); 3) Conditional (rules); and 4) Procedural (how to). In contrast to the index which is stored in regular structures for rapid access (like relational databases), the knowledge records are stored in free text (variable length) and may include pointers to imaging and audio records. A particular feature of the FRAMEMED system is careful attention to modifiers, an aspect usually not emphasized in other systems. In trying to structure the free text describing a patient encounter, for example, the major concepts such as cough, fever, stiff neck, etc., are relatively easy to code (although a common system has not yet been agreed upon). The devil lies in the modifiers such as 'history of', 'severe,' 'constant,' 'absent,' 'left,' 'abnormal,' etc., particularly when there is concatenation of modifiers modifying modifiers. Our Relational records (in our knowledge base) and our Chronological Medical Records (CMR) in our patient record have the same format, namely, a title, several related items, and a date/author. For example, our disease profile (Relational record) for 'Influenza' might include 'cough,' 'fever,' and 'stiff neck.' The CMR of a particular patient encounter might include the same items. The only differences would be the title (disease name for the disease profile, date for the CMR, and the omission of the redundant date in the date/author line of the CMR). Each related item in either of these records is expressed in a four-part string, namely: 1) Relation; 2) Code; 3) Phrase; and 4) Comment. Modifiers (common ASCII symbols) are structured into each of these parts. For example, if the patient did not have 'cough,' the default '+' in the Relation would be edited to a '-', while 'history of' cough would be '>'. Each Relation can be graded (on a 5-level scale) for both importance and frequency. The Code for a test can carry the result suffix, '+ positive/high,' '-negative/low,' '# abnormal (qualitatively)', or '1 unremarkable/normal.' Topological information, such as '/left,' can be appended to a Code. If the cough is getting worse, its code can have the suffix, '<'. The standardized Phrases associated with the Codes come from the hierarchical lists of the index section described earlier. Phrases are not stored, being rematched to the codes as needed for user display. This practice not only saves memory space but allows a CMR encounter recorded in one language to be displayed in another second language subsequently, requiring only the existence of the hierarchical code/phrase in the second language. A free-text Comment is allowed for any related item in a Relational record or CMR, to allow the doctor to add important nuances such as 'worse on arising' or for a numeric result such as a test result or a thermometer reading. Some structuring can be accommodated in the Comment by introducing symbols such as '> relieved by,' followed by a list containing entries such as 'antacids.' Time can be sturctured through symbol lists such as '@-2 mo' representing '2 months previously.' Because Relational records in the knowledge ase and patient encoutner records in the CMR both display findings in hierarchical order; all similar items (e.g., Agents, Clinical Manifestations, Tests, Procedures, etc.) occur together and in an unique order. (abstract truncated)

Abstracting and Indexing↗
PubMed1995

Image-oriented rule generating tool for medical knowledge base.

This paper describes an automatic programming tool for the end users in the medical knowledge representation. When end users work with the rule generating tool (RGT) that we have designed, they can represent an idea using an Image-oriented interface such as a picture, movie, audio reference or two dimensional bar code. Such representations can be valuable tools for medical study, diagnosis, decision making and treatment monitoring to supplement the expertise of medical personnel. The RGT will automatically generate rules in the logic programming language Prolog and then add them to the knowledge base.

Algorithms↗