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Developing the health information infrastructure in the United States.

Consumers, patients, and their families; health care providers and managers; public health professionals and policy makers need integrated multi-function health information structures that allow them to locate and apply information when and where they need it to make better decisions about health. The National Committee on Vital and Health Statistics (NCVHS), which advises the Secretary of Health and Human Services (HHS) on health information policy, is promoting a comprehensive vision of the National Health Information Infrastructure (NHII). The NHII is defined as the set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health. It is not a unitary database. The broad goal of the NHII is to deliver information to consumers, patients, professionals, and other health decision-makers when and where they need it. The NCVHS' Interim Report presented three overlapping "dimensions" of the NHII: the personal health dimension, the health care provider dimension, and the community health dimension, to highlight the functions and value of information linkages from various perspectives. The content of an NHII includes clinical, population, and personal data, practice guidelines, biomedical, health services, and other research findings; and consumer health information. This data is, and will likely remain, stored in many locations. To succeed, such an effort will require coordinated, collaborative action. The NCVHS' final report to the HHS Secretary will include recommendations for Federal leadership and for other relevant stakeholders, including public health agencies; health care providers, plans and purchasers; the IT industry; standards development organizations; and consumer groups.

Health Policy↗

Future of medical knowledge management and decision support.

Attempts to predict the future are typically off the mark. Beyond the challenges of forecasting the stock market or the weather, dramatic instances of notoriously inaccurate prognostications have been those by the US patent office in the late 1800s about the future of inventions, by Thomas Watson in the 1930s about the market for large computers, and by Bill Gates in the early 1990s about the significance of the Internet. When one seeks to make predictions about health care, one finds that, beyond the usual uncertainties regarding the future, additional impediments to forecasting are the discontinuities introduced by advances in biomedical science and technology, the impact of information technology, and the reorganizations and realignments attending various approaches to health care delivery and finance. Changes in all three contributing areas themselves can be measured in "PSPYs", or paradigm shifts per year. Despite these risks in forecasting, I believe that certain trends are sufficiently clear that I am willing to venture a few predictions. Further, the predictions I wish to make suggest a goal for the future that can be achieved, if we can align the prevailing political, financial, biomedical, and technical forces toward that end. Thus, in a sense this is a call to action, to shape the future rather than just let it happen. This chapter seeks to lay out the direction we are heading in knowledge management and decision support, and to delineate an information technology framework that appears desirable. I believe the framework to be discussed is of importance to the health care-related knowledge management and decision making activities of the consumer and patient, the health care provider, and health care delivery organizations and insurers. The approach is also relevant to the other dimensions of academic health care institution activities, notably the conduct of research and the processes of education and learning.

Biomedical Technology↗

The future of medical computing.

The practice of medicine is inherently dependent upon health technology. Clinicians use a wide variety of technologies in diagnosing, treating, and assessing the care of their patients. In this book, The Future of Health Technology, many different aspects of health technology are discussed in detail. Considering this breadth of coverage, it is challenging to ascertain what remains to be discussed in this chapter on "the future of medical computing". Given this considerable coverage, this chapter will open with a brief vision of the future of medical computing from three perspectives--the Patient, the Ambulatory Provider, and the Hospitalist. Discussion follows on the current and future driving forces for change in healthcare technology, and an overview of the unresolved issues that must be addressed. Necessarily, this chapter will not provide more than an overview of these topics and issues. Rather, it is the author's intent to present several visions of the future of medical computing and outline the issues, which must be overcome to achieve the vision.

Ambulatory Care↗

MedReach: building an Area Health Education Center medical information outreach system for northwest Ohio.

In collaboration with regional partners in northwest Ohio, the Area Health Education Center (AHEC) program at the Medical College of Ohio (MCO) at Toledo is reaching out to underserved areas, helping to provide educational opportunities to health care professionals in these communities. This paper describes the development of MedReach, a medical information outreach system that connects regional AHEC sites to MCO via the Internet. MedReach provides physicians and other health care professionals access and support to search computerized textbooks and databases for current information on medical diagnoses, treatments, and research. A unique aspect of the MedReach project is that users are able to receive personal help with information retrieval by calling or emailing MCO's outreach librarian. Periodically, the AHEC program and the Mulford Library at MCO also sponsor an educational program, titled "Medical Applications of Computers," for regional practitioners. Current feedback on both the medical information outreach system and the educational program has been positive.

Area Health Education Centers↗

Redefining and improving patient safety.

OBJECTIVES: The Institute of Medicine (IOM) has focused attention on patient safety in the United States. Other countries share these concerns. METHODS: Governmental agencies and professional organizations are redefining approaches to safety, calling upon the use of information and communication technology as an enabler and expanding the range of evidence admissible in documenting success. RESULTS: Efforts to understand medical errors have used retrospective chart review, incident reporting, and computerized surveillance; the result is an evolving picture of the number, nature, and cause of errors. Approaches used to prevent errors include computerized physician order entry, decision support tools, computerized monitoring, and evidence-based practice; varying levels of evidence document their success. CONCLUSIONS: Technology offers challenging capabilities, not simple solutions. New evidence and new tools demand new approaches and attention to human factors.

Decision Support Techniques↗

Requirements Engineering for inter-organizational health information systems with functions for spatial analyses: modeling a WHO safe community applying Use Case Maps.

OBJECTIVES: To evaluate Use Case Maps (UCMs) as a technique for Requirements Engineering (RE) in the development of information systems with functions for spatial analyses in inter-organizational public health settings. METHODS: In this study, Participatory Action Research (PAR) is used to explore the UCM notation for requirements elicitation and to gather the opinions of the users. The Delphi technique is used to reach consensus in the construction of UCMs. RESULTS: The results show that UCMs can provide a visualization of the system's functionality and in combination with PAR provide a sound basis for gathering requirements in inter-organizational settings. UCMs were found to represent a suitable level for describing the organization and the dynamic flux of information including spatial resolution to all stakeholders. Moreover, by using PAR, the voices of the users and their tacit knowledge is intercepted. Further, UCMs are found useful in generating intuitive requirements by the creation of use cases. CONCLUSIONS: With UCMs and PAR it is possible to study the effects of design changes in the general information display and the spatial resolution in the same context. Both requirements on the information system in general and the functions for spatial analyses are possible to elicit when identifying the different responsibilities and the demands on spatial resolution associated to the actions of each administrative unit. However, the development process of UCM is not well documented and needs further investigation and formulation of guidelines.

Delivery of Health Care↗

The index as a new concept towards an integrated framework for the electronic patient record.

OBJECTIVE: To overcome some classical limitations of the POMR (Problem-Oriented Medical Record), including the management of divergent opinions between health professionals, in order to construct a common patient record across multiple disciplines in hospital settings and professional networks. METHODS: Using a complex clinical case, we improved a POMR model previously used by GPs in order to translate it into a hospital setting. The enhanced model has been assessed through use in various ongoing clinical cases and through extended discussion with professional end-users (physicians, nurses, general practitioners, and social workers). RESULTS: The Index concept (flexible structural link) is proposed as a major improvement in the construction of a POMR in a shared care environment. CONCLUSIONS: The Index introduces interesting new perspectives. Following its implementation in the Belgian pilot site in the CORINES project, further studies remain to be carried out in order to develop a cost/benefit assessment.

Humans↗

PA education in an evolving health care system.

Remarkable changes in medicine and education have created opportunities to redefine physician assistant (PA) education in a new context. The result has been the evolution of a dynamic and fluid educational model, one that is responsive to changes in the content and delivery of the PA curriculum. Development of new skills related to practice management and mechanisms for health services delivery, particularly for the growing numbers of uninsured and disenfranchised patients, presents a particular challenge. Curriculum planning includes strategies to deliver new knowledge and skills in medical informatics, communication, and cultural competencies, as well as evolving content such as alternative and complementary medicine, genetics, and telemedicine.

Clinical Competence↗

Clinical decision support systems: a discussion of quality, safety and legal liability issues.

Developers of Clinical Decision Support Systems (CDSSs) have to date been more concerned with the efficacy of systems (e.g. measurable improvements in clinical outcomes) than with safety (e.g. potential for harmful side-effects). In future CDSS developers will be required (by the courts etc.) to acknowledge a "duty of care" covering all aspects of design, development and deployment. Experience in the transport, power and other safety-critical industries has led to a range of quality and safety assurance methods whose adoption may be needed before CDSSs can safely become an integral part of routine patient care, and before the trust of healthcare professionals, patients and other stakeholders can be gained. No single method will be sufficient for safe development and deployment; a range of techniques will be needed and used selectively. This paper is a contribution to discussion of quality, safety and legal liability issues in the medical informatics community.

Decision Support Systems, Clinical↗

The Chronus II temporal database mediator.

Clinical databases typically contain a significant amount of temporal information. This information is often crucial in medical decision-support systems. Although temporal queries are common in clinical systems, the medical informatics field has no standard means for representing or querying temporal data. Over the past decade, the temporal database community has made a significant amount of progress in temporal systems. Much of this research can be applied to clinical database systems. This paper outlines a temporal database mediator called Chronus II. Chronus II extends the standard relational model and the SQL query language to support temporal queries. It provides an expressive general-purpose temporal query language that is tuned to the querying requirements of clinical decision support systems. This paper describes how we have used Chronus II to tackle a variety of clinical problems in decision support systems developed by our group.

Database Management Systems↗

Leveraging on information technology to enhance patient care: a doctor's perspective of implementation in a Singapore academic hospital.

Information technology (IT) can improve the safety of patient care by minimising prescribing errors and organising patient-specific information from diverse databases. Apart from legibility, prescribing safety is enhanced as online access to databases carrying patient drug history, scientific drug information and guideline reference, and patient-specific information is available to the physician. Such specific information includes discharge summaries, surgical procedure summaries, laboratory data and investigation reports. In addition, decision support and prompts can be built in to catch errant orders. For such system implementations to work, the IT backbone must be fast, reliable and simple to use. End-user involvement and ownership of all aspects of development are key to a usable system. However, the hospital leadership must also have the will to mandate and support these development efforts. With such support, the design and implementation team can then map out a strategy where the greatest impact is achieved in both safety and enhanced information flow. The system should not be considered a finished work, but a continual work in progress. The National University Hospital's continuously updated Computerised Patient Support System (CPSS) is an example of an IT system designed to manage information and facilitate prescribing. It is a client-server based, one-point ordering and information access portal for doctors that has widespread adoption for drug prescription at outpatient and discharge medication usage areas. This system has built in safety prompts and rudimentary decision support. It has also become the choice means of accessing patient-related databases that impact on diagnoses and management.

Attitude of Health Personnel↗

Computer crash.

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Academic Medical Centers↗