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Medical informatics--an Australian perspective.

Computers, like the X-ray and stethoscope can be seen as clinical tools, that provide physicians with improved expertise in solving patient management problems. As tools they enable us to extend our clinical information base, and they also provide facilities that improve the delivery of the health care we provide. Automation (computerisation) in the health domain will cause the computer to become a more integral part of health care management and delivery before the start of the next century. To understand how the computer assists those who deliver and manage health care, it is important to be aware of its functional capabilities and how we can use them in medical practice. The rapid technological advances in computers over the last two decades has had both beneficial and counterproductive effects on the implementation of effective computer applications in the delivery of health care. For example, in the 1990s the computer hobbyist is able to make an investment of less than $10,000 on computer hardware that will match or exceed the technological capacities of machines of the 1960s. These rapid technological advances, which have produced a quantum leap in our ability to store and process information, have tended to make us overlook the need for effective computer programmes which will meet the needs of patient care. As the 1990s begin, those delivering health care (eg, physicians, nurses, pharmacists, administrators ...) need to become more involved in directing the effective implementation of computer applications that will provide the tools for improved information management, knowledge processing, and ultimately better patient care.

Australia↗

Influence of strategic direction for NHS Scotland knowledge services on indexing policy for the NHS Scotland e-library.

OBJECTIVES: Indexing policy for the NHS Scotland e-Library needs to maximize future inter-operability with other significant health- and social-care-related resources. The strategic drive towards integration and partnership working means that the indexing system has to be widely acceptable to the full range of disciplines within the integrated health-care family. METHODS: Indexes identified by various means and then shortlisted using predefined criteria. RESULTS: Three subject indexes have been chosen--Medical Subject Headings (MeSH), CareData and the Government Category List (GCL), plus mapping between natural language and MeSH terms. This decision was a reasonable compromise between the strategy-driven aim of seamless access for all 'partners in care', and practical constraints of time/manpower. Other authority files (e.g. geographical area, language) are also standards based, and customised to reflect the information needs of an increasingly integrated health-care system. CONCLUSIONS: No single index could provide the scope required to meet the widening range of NHS information need. The influence of high-level strategic aims and objectives have extended their reach to influence indexing policy for the e-Library. Our indexing policy will continue to evolve and contribute to a knowledge management infrastructure capable of supporting current and future NHS Scotland information needs and strategy. Layperson terminology was identified as a gap; additional measures to address this gap are highlighted.

Abstracting and Indexing↗

Information needs of specialist healthcare professionals: a preliminary study based on the West of Scotland Colorectal Cancer Managed Clinical Network.

OBJECTIVES: Funded by Research in the Workplace Award (RIWA) 2001, the study investigated the information needs and use of NHS library services by members of the West of Scotland Colorectal Cancer Managed Clinical Network (MCN), a single subject, cross boundary, multi-professional organization. METHOD: A postal questionnaire sent out in October 2002 was returned by 100 members and follow-up interviews were held in March 2003 with 11 of the respondents. The questions related to access to resources, library services such as literature searches, current awareness and training. They also explored the use of electronic resources and the Internet. RESULTS: Respondents were mainly hospital doctors and a few nurses from across five health boards. Most had access to a library, although not all made use of it, possibly an indication of the need for improved communications between librarians and health-care staff. Generally, research and professional development were reported as reasons for needing cancer information, but on further investigation the motivation to conduct literature searches was more related to patient care. Examples included treatment of unusual cases, locating information for patients and identifying guidelines. There are indications of unmet needs for local contact information and evaluated patient information. CONCLUSION: Development of a cancer portal within the NHS Scotland e-Library available from May 2004 based on the Managed Knowledge Network (MKN) concept is attempting to address many of the issues raised in the survey, including inequities of access to services and signposting to a variety of types of information.

Colorectal Neoplasms↗

A framework for evidence-based mental health care and policy.

OBJECTIVE: Care planning integrates a growing number of disciplines, research fields and analysis techniques. A framework of the main areas of interest with regard to evidence-based health care in mental health is provided here. METHOD: The framework is based on the experience of working with data analysts and health and social decision makers at the PSICOST/RIRAG network, a Spanish research association which includes psychiatrists, health economists and health policy experts, as well as on a review of the literature. RESULTS: Three main areas have been identified and described here: outcomes management, knowledge discovery from data, and decision support systems. Their use in mental health care is reviewed. CONCLUSION: It is important to promote bridging strategies among these new fields in order to enhance communication and information transfer between the different parts involved in mental health decision making: i) clinicians and epidemiologists, ii) data analysts, iii) care policy makers and other end-users.

Evidence-Based Medicine↗

Using the Open Airways curriculum to improve self-care for third grade children with asthma.

A 12-week, pilot intervention study was conducted in five elementary schools with third grade children who have asthma to test instruments, feasibility of providing the Open Airways classes in less time, and to identify potential problems in study implementation. The sample consisted of 10 boys and five girls ranging in age from 8-9.5 years. Asthma management knowledge improved significantly (t = -2.30, p = .019). Findings supported the reliability and readability of the instruments and the feasibility of briefer class sessions. The Open Airways curriculum can be modified to facilitate delivery to school-based groups without interfering with academic time.

Asthma↗

Developments in management of the newborn foal in respiratory distress 2: Treatment.

New developments in therapy for foals in respiratory distress are discussed. Therapy is based on preservation of the foal's life by maintenance of a patent airway, resuscitation with fluids and warmth, provision of humidified oxygen to raise the fractional concentration of inspired oxygen sufficient to avoid hypoxia and provision of ventilatory support when hypercapnia becomes critical. Ventilatory support described includes assisted and controlled ventilation, positive end expiratory pressure, continuous positive airway pressure and intermittent mandatory ventilation. The aims of these techniques are discussed together with their associated indications, disadvantages and complications. Secondary therapy includes coupage, airway hygiene, drug therapy and stress management. Knowledge of equine neonatology is limited in comparison with human neonatology. More information in basic physiology and pharmacology relating to equine neonatology is needed and the efficacy of various modes of therapy must be evaluated.

Animals↗

My approach to superficial inflammatory dermatoses.

Superficial inflammatory dermatoses are very common and comprise a wide, complex variety of clinical conditions. Accurate histological diagnosis, although it can sometimes be difficult to establish, is essential for clinical management. Knowledge of the microanatomy of the skin is important to recognise the variable histological patterns of inflammatory skin diseases. This article reviews the non-vesiculobullous/pustular inflammatory superficial dermatoses based on the compartmental microanatomy of the skin.

Dermatitis↗

Continuous quality improvement: educating towards a culture of clinical governance.

The National Health Service in England and Wales has recently adopted a policy aimed at embedding continuous quality improvement (CQI) at all levels and across all services. The key goal is to achieve changes in practice which improve patient outcomes. This paper describes the use of a training course for multiprofessional groups of participants tailored to offer them relevant knowledge, management and team working skills, and approaches to personal and career development. These were intended to assist them in changing their practice for the benefit of patients. The participants rated the course highly in fulfilling its objectives. One cohort followed up for 6 months named changes in practice which related specifically to learning from the course. This paper shows the important contribution of multiprofessional learning to CQI and presents a useful method of evaluating links between learning and performance.

Education, Continuing↗

Clinicians, librarians and patient safety: opportunities for partnership.

Librarians could improve the safety of medical care through greater participation in patient safety initiatives. A librarian's expertise in accessing the evidence base could enhance the safety and appropriateness of care in a clinical environment. In addition, librarians could apply specific technical knowledge management skills to medicine. To realize improvements from these skill sets, healthcare leaders must consider ways of working with librarians to enhance patient safety.

Cooperative Behavior↗

The biology of tobacco and nicotine: bench to bedside.

Strong epidemiologic evidence links smoking and cancer. An increased understanding of the molecular biology of tobacco-related cancers could advance progress toward improving smoking cessation and patient management. Knowledge gaps between tobacco addiction, tumorigenesis, and cancer brought an interdisciplinary group of investigators together to discuss "The Biology of Nicotine and Tobacco: Bench to Bedside." Presentations on the signaling pathways and pathogenesis in tobacco-related cancers, mouse models of addiction, imaging and regulation of nicotinic receptors, the genetic basis for tobacco carcinogenesis and development of lung cancer, and molecular mechanisms of carcinogenesis were heard. Importantly, new opportunities to use molecular biology to identify and abrogate tobacco-mediated carcinogenesis and to identify high-risk individuals were recognized.

Animals↗

Predictors of depression after stroke: a systematic review of observational studies.

BACKGROUND AND PURPOSE: Although depression is common after stroke, there is uncertainty over its etiology and risk factors, which complicates management. Knowledge of the predictors of depression associated with stroke may allow for the better targeting of therapy, both prevention and treatment. METHODS: We undertook a systematic review of all published, nonexperimental, population-, hospital-, and rehabilitation-based stroke studies (to June 2004) with prospective, consecutive patient recruitment undertaken to identify variables associated with depressive symptoms (or "illness") after stroke. Assessments were made of the quality of studies including the validity of prognostic models. RESULTS: Data were available from 3 population-based studies including 492 patients, 8 hospital-based studies including 15,272 patients, and 9 rehabilitation-based studies including 2170 patients. Physical disability, stroke severity and cognitive impairment were consistently associated with depression. In addition to the common problem of selection bias, major limitations of these studies included variable selection and poor statistical quality and reporting; small sample sizes meant that only a limited range of variables were analyzed in multivariate models. CONCLUSIONS: There is a paucity of well-designed studies of sufficient size to allow stable multivariate predictive models of depression after stroke to be developed. Other than showing that depression is associated with more severe strokes, current evidence does not allow for ready identification of patients most at risk of developing this important complication of stroke.

Aged↗

Introducing the National Library for Health Skin Conditions Specialist Library.

BACKGROUND: This paper introduces the new National Library for Health Skin Conditions Specialist Library http://www.library.nhs.uk/skin. DESCRIPTION: The aims, scope and audience of the new NLH Skin Conditions Specialist Library, and the composition and functions of its core Project Team, Editorial Team and Stakeholders Group are described. The Library's collection building strategy, resource and information types, editorial policies, quality checklist, taxonomy for content indexing, organisation and navigation, and user interface are all presented in detail. The paper also explores the expected impact and utility of the new Library, as well as some possible future directions for further development. CONCLUSION: The Skin Conditions Specialist Library is not just another new Web site that dermatologists might want to add to their Internet favourites then forget about it. It is intended to be a practical, "one-stop shop" dermatology information service for everyday practical use, offering high quality, up-to-date resources, and adopting robust evidence-based and knowledge management approaches.

Databases as Topic↗

Decision tools in health care: focus on the problem, not the solution.

BACKGROUND: Systematic reviews or randomised-controlled trials usually help to establish the effectiveness of drugs and other health technologies, but are rarely sufficient by themselves to ensure actual clinical use of the technology. The process from innovation to routine clinical use is complex. Numerous computerised decision support systems (DSS) have been developed, but many fail to be taken up into actual use. Some developers construct technologically advanced systems with little relevance to the real world. Others did not determine whether a clinical need exists. With NHS investing 5 billion pounds sterling in computer systems, also occurring in other countries, there is an urgent need to shift from a technology-driven approach to one that identifies and employs the most cost-effective method to manage knowledge, regardless of the technology. The generic term, 'decision tool' (DT), is therefore suggested to demonstrate that these aids, which seem different technically, are conceptually the same from a clinical viewpoint. DISCUSSION: Many computerised DSSs failed for various reasons, for example, they were not based on best available knowledge; there was insufficient emphasis on their need for high quality clinical data; their development was technology-led; or evaluation methods were misapplied. We argue that DSSs and other computer-based, paper-based and even mechanical decision aids are members of a wider family of decision tools. A DT is an active knowledge resource that uses patient data to generate case specific advice, which supports decision making about individual patients by health professionals, the patients themselves or others concerned about them. The identification of DTs as a consistent and important category of health technology should encourage the sharing of lessons between DT developers and users and reduce the frequency of decision tool projects focusing only on technology. The focus of evaluation should become more clinical, with the impact of computer-based DTs being evaluated against other computer, paper- or mechanical tools, to identify the most cost effective tool for each clinical problem. SUMMARY: We suggested the generic term 'decision tool' to demonstrate that decision-making aids, such as computerised DSSs, paper algorithms, and reminders are conceptually the same, so the methods to evaluate them should be the same.

Attitude to Computers↗

Organizational interventions to implement improvements in patient care: a structured review of reviews.

BACKGROUND: Changing the organization of patient care should contribute to improved patient outcomes as functioning of clinical teams and organizational structures are important enablers for improvement. OBJECTIVE: To provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care. DESIGN: Structured review of published reviews of rigorous evaluations. DATA SOURCES: Published reviews of studies on organizational interventions. REVIEW METHODS: Searches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003. Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings. RESULTS: A total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain. CONCLUSION: There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty.

Journal Article↗

An integrated approach to consumer representation and involvement in a multicentre randomized controlled trial.

Although, consumer involvement in individual studies is often limited, their involvement in guiding health research is generally considered to be beneficial. This paper outlines our experiences of an integrated relationship between the organisers of a clinical trial and a consumer organisation. The PRISM trial is a UK multicentre, randomized controlled trial comparing treatment strategies for Paget's disease of the bone. The National Association for the Relief of Paget's Disease (NARPD) is the only UK support group for sufferers of Paget's disease and has worked closely with the PRISM team from the outset. NARPD involvement is integral to the conduct of the trial and specific roles have included: peer-review; trial steering committee membership; provision of advice to participants, and promotion of the trial amongst Paget's disease patients. The integrated relationship has yielded benefits to both the trial and the consumer organisation. The benefits for the trial have included: recruitment of participants via NARPD contacts; well-informed participants; unsolicited patient advocacy of the trial; and interested and pro-active collaborators. For the NARPD and Paget's disease sufferers, benefits have included: increased awareness of Paget's disease; increased access to relevant health research; increased awareness of the NARPD services; and wider transfer of diagnosis and management knowledge to/from health care professionals. Our experience has shown that an integrated approach between a trial team and a consumer organisation is worthwhile. Adoption of such an approach in other trials may yield significant improvements in recruitment and quality of participant information flow. There are, however, resource implications for both parties.

Consumer Organizations↗

A short history of the William H. Welch Medical Library.

The William H. Welch Medical Library was founded in 1929 with the merger of three libraries, namely, the library of the School of Medicine, the library of the School of Hygiene and Public Health, and the library of the Johns Hopkins Hospital. Engendered by the dreams of Johns Hopkins University bibliophiles, such as founding Hopkins physicians William Osler, William Stewart Halsted, Howard Kelly, and William Henry Welch, the library flourished and expanded. At the same time as the founding of the central medical library, the Institute of the History of Medicine collection was established in the Welch Library building, with William H. Welch as its first director. Innovative leadership led to many exciting projects, such as the Welch Indexing Project, which was a prototype for the National Library of Medicine's medical subject headings, and the establishment of a laboratory for research into the application of information technologies to knowledge management. The Welch Library enters the 21st century as a dynamic library committed to the continuing delivery of information services, as well as ongoing research into the development of library services for the coming 100 years.

Academic Medical Centers↗

Broadband multimedia for education.

Over the next five to ten years the accelerating development of computing and broadband networks will lead to a revolution in the ways in which health care is delivered. Patients will spend less time in the great institutions of the tertiary hospitals and the illnesses taking them there will assume a different pattern. The new information technologies will foster the emergence of general practices with a new emphasis on keeping patients in their communities for medical management. Knowledge exchange and delivery--to both patient and practitioner--will therefore become an increasingly important component of the health-care system in the next millennium.

Australia↗

The initiation of distance learning at Thomas Jefferson University: the library as integral partner.

In 1998 Thomas Jefferson University offered its first entirely online course. Librarians and library staff were integral in the development, support, evaluation, and refinement of this course. While staff members may have taken non-traditional roles in this effort, their roles generally fell within the broad guidelines of assisting University faculty with information and knowledge management. The development and support of distance course offerings will continue to be a focus at Scott Memorial Library.

Curriculum↗