Biomedical subjects
Publications and source records attributed to W E Hammond.
Healthcare standards in the US are produced by six standard developers organizations: ACR/NEMA, ASC X12N, ASTM, HL7, IEEE, and NCPDP. The activities of these groups are coordinated through the ANSI HISPP. While considerable progress has been made in the area of data interchange standards, little progress has been made in the area of vocabulary standards.
BACKGROUND: The purpose of this study was to develop and evaluate a computer system that would translate patient diagnoses noted by a physician into appropriate International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes and maintain a patient-specific up-to-date problem list. METHODS: The intervention consisted of a computerized list (dictionary) of diagnoses, including practice-specific synonyms and abbreviations, linked to their corresponding ICD-9-CM codes. To record the diagnoses for the office visit before the intervention, physicians used International Classification of Health Problems in Primary Care (ICHPPC-2) codes. After the intervention, physicians used their own words or checked previously identified diagnoses on the computer-generated problem list. The computer then identified the correct ICD-9-CM code. Accuracy of coding was compared before and after the new computerized system was implemented. RESULTS: Visits in which all diagnoses matched increased from 58% to 76% (P < .001) with use of the computer system. Visits in which no computer diagnoses matched the chart decreased from 22% to 8% (P < .001). Errors of omission declined from 38% to 18% (P < .001). Errors of commission decreased from 19% to 11% (P = .006). Overall accuracy increased from 62% to 82% (P < .001). CONCLUSIONS: Outpatient medical diagnosis coding can be simplified and accuracy improved by using a computerized dictionary of practice-specific diagnoses and synonyms linked to appropriate ICD-9-CM codes. Such a system provides a computer-generated problem list that accurately reflects the chart and assists with prompted coding on subsequent visits.
The analysis of clinical data collected over time can provide important insight into the health care process. Unfortunately, much of the electronic clinical data that exists today is stored in legacy systems, making it difficult to access and share the information. An approach is needed to improve the accessibility of electronic data stored in legacy system databases. In this study, a legacy database is converted into a relational format in the personal computer environment. The impact of such a conversion on query performance is evaluated, and issues that need to be considered when converting a legacy system database are identified.
OBJECTIVE: To assess the feasibility and potential clinical usefulness of the computerized Duke Severity of Illness Checklist (DUSOI). DESIGN: Cross-sectional study of patients whose severity of illness was measured with the DUSOI. Providers assessed the clinical usefulness of the DUSOI and recorded the length of time required for rating severity. Auditors rated severity using progress note information. Demographic and financial data from clinic records were also obtained. SETTING: University-based family practice clinic with 64,621 annual visits. PATIENTS: Convenience sample of ambulatory patients. MAIN OUTCOME MEASURES: Clinical usefulness and time required to rate severity. RESULTS: For 117 patients (63.3% female; mean age, 46.3 years), the mean charge was $105.38, the mean number of health problems was 2.0, the mean overall provider DUSOI score was 33.7, and the mean auditor DUSOI score was 34.0 (scale = 0 to 100). There was excellent agreement between provider and auditor DUSOI scores (intraclass correlation coefficient, .77). Providers required 1.1 minutes to record severity; the principal auditor required 1.6 minutes. Providers found the DUSOI potentially useful in 30.3% of patients. Usefulness was greater in women (38.2% of women vs 18.2% of men), older patients (mean age, 54.5 years in useful group vs 41.9 in nonuseful group), and sicker patients (mean DUSOI score, 55.1 vs 25.9). The DUSOI was more clinically useful in patients with health problems such as type II diabetes mellitus (75.0%) than in those with problems such as tobacco use (25.0%). Higher charges correlated with a higher number of health problems and with female gender but not with severity scores. CONCLUSIONS: The computerized DUSOI is feasible for all patients and is potentially useful for women, older, and sicker patients.
In the belief that the existence of a variety of standards is an absolute necessity for health care professional workstations to work, this paper provides a detailed overview of the standards efforts of a number of groups. According to the International Standards Organization (ISO) Reference Model, workstations require a full level of standards from the physical level through and beyond the applications level. Rapidly changing technology challenges acceptance of standards at the lower levels. Current recommendations include fiberoptic media using certain protocols. Other standards in these lower levels also have support. At the applications level, data messaging standards are being developed by six groups. The consensus standards body for the United States is coordinating the efforts of these groups in order to produce a harmonized effort, and is coordinating the effort with Europe for an international effort. Work on the development of the full set of standards necessary for workstation implementations is lagging. Accelerating the process is mandatory if we are to achieve the necessary seamless interoperability required by workstations for ubiquitous intelligent communications between the workstations and the sources of data.
Disease-specific standards for directing patient management are becoming increasingly important. These standards, however, are often not followed because they are not sufficiently integrated into the clinical care setting. In this study we describe the development and evaluation of a Computer-Assisted Management Protocol (CAMP) of care guidelines for diabetes mellitus. While other studies have shown improved compliance with rule-based reminders, the CAMP customizes disease-specific care guidelines to individual patients over time. We evaluated the effect of the CAMP on compliance with guidelines in a prospective, randomized controlled study. The study was performed at a family practice clinic where much of the patient record is maintained electronically on The Medical Record (TMR). The management protocol was developed from standards published by the American Diabetes Association. Fifty-eight providers were randomized to either receive or not receive the CAMP for diabetes. Compliance with standards was assessed by chart audits of all encounters with diabetic patients during the study interval. The following conclusion was made: the Computer-Assisted Management Protocol resulted in a statistically significant improvement in compliance with diabetes care standards.
OBJECTIVES: An analytic descriptive analysis of acute childbirth morbidity was carried out at Duke University Medical Center, comparing patients delivered by primary cesarean section with those delivered vaginally. STUDY DESIGN: All primary cesarean deliveries and vaginal deliveries from July 1, 1981, through June 30, 1986, were combined with maternal and infant charge data. A total of 7256 patients were analyzed. A description of the charges for the associated diagnoses was carried out. A morbidity index was used to identify differences in predicted median hospital charges with 95% confidence intervals. RESULTS: The ratio of mean primary cesarean delivery to mean vaginal delivery total charges was 2.5:1. The magnitude of the mean hospital charges was inversely related to the frequency of the indication with the lowest charges associated with dystocia and the highest with multiple pregnancy. Antepartum risk factors (increased maternal age, patient referral) were associated with increases in maternal and infant morbidity as measured by the morbidity index. Chronic maternal hypertension resulted in decreased maternal morbidity but increased infant morbidity when primary cesarean delivery was used. Although preterm delivery was associated with large increases in charges, it was not significantly altered by using primary cesarean delivery. Risk factors associated with the management of abnormalities of labor were associated with decreases in maternal and infant morbidity when primary cesarean delivery was used. CONCLUSION: Analysis of acute childbirth morbidity, as measured by hospital charges, showed marked variation of diagnosis and risk-specific charges for patients delivered by primary cesarean section.
This paper describes the design considerations for the implementation of a bedside computer system in an intensive care environment. Specific issues discussed include application design, implementation problems, design revisions, and design solutions. Specific examples of the above issues include passive data acquisition from bedside devices and computer systems, automated nursing assessments, respiratory therapy assessments and integrated reports.
A major problem which must be overcome before on-line medical records become widely accepted and used is the interface between the human and the computer. This paper presents the evolution of an interface, over time, which recognizes and addresses important characteristics a system must exhibit to encourage human acceptance. Areas discussed include data entry, displays, and function and parameter specifications.
Explore the source record for details and available documents.
There was a steady increase in the yearly cesarean delivery rate, from 14.0 to 24.8%, between July 1, 1978 and June 30, 1986 at Duke University Medical Center; this was associated predominantly with an increase in the rate of primary cesarean deliveries. The three most frequent major diagnoses associated with primary cesarean delivery changed significantly over the study period. Fetal compromise became the most commonly associated diagnosis (from third), dystocia second (from first), and maternal disease third (from second). The categories of fetal positional abnormalities (fourth), abnormalities of placentation (fifth), and multiple pregnancy (sixth) did not change in rank. Primary cesarean delivery patients were compared with patients who delivered vaginally using odds ratios, prevalence, and population-attributable fractions. The risk factors of nulliparity, gestational age less than 37 weeks, late decelerations, and referral had the largest impact on the primary cesarean rate. Decreases in rates related to an increased tolerance of abnormalities of labor were overshadowed by the effects of increased concerns related to fetal health.
Explore the source record for details and available documents.
A model for improving physician prescribing that utilizes computerized feedback was studied in a family medicine residency practice. Resident and faculty physicians were stratified by level of experience and randomized into two groups. For 9 months the experimental group received monthly printouts identifying drugs they had prescribed by brand name with estimates of cost savings that might have been realized by prescribing generic drugs. The control group received no feedback. Prescription monitoring of both groups continued for 12 months after all feedback had ceased. Median weighted rates of generic prescribing for the experimental physicians were 14% for the baseline, 67% for the feedback, and 54% for the follow-up periods. Rates for the control physicians for the three periods were 32%, 37% and 31%, respectively. The increase in generic prescribing by physicians in the experimental group was significantly greater than for control physicians (P = 0.01). The feedback model improved rates of generic prescribing but should be evaluated for broader areas of physician prescribing.
A computerized medical record changes the way a clinician practices medicine by presenting data about patients in multiple organized formats. A computerized record can be used to make it more difficult to overlook important findings. The computer can improve communication by informing both the patient and referring physicians of new data as they become available. Computer graphics or algorithms can be used to emphasize subtle trends. A computer data base can be used to aggregate data about selected patients to provide information about the natural history of disease and effect of treatment.
The use of computerized medical records for complex medical patients will depend upon the transfer of previous medical data from the manual record into the automated version. The complexity of these patients precludes the complete transfer of medical data into the automated record because of time requirements. This paper describes a method of transfer of medical data from the manual record to the computerized record that is efficient, accurate, and useful.
The computerized medical record supported by The Medical Record (TMR) has been the only record of physician-patient encounters on the nephrology service of the Durham Veterans Administration Medical Center since April 1981. Physicians using the system evaluated the adequacy of the computerized record as a replacement for the paper chart. The computerized record was able to capture and display all pertinent data. Manual or computerized narratives provided a useful supplement to the core computerized record only in those rare instances that a physician needed to point out which of the data in the record were important to his decision making.
Explore the source record for details and available documents.
Explore the source record for details and available documents.