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PubMed1992

A computerized documentation system for cancer pain management units.

A cancer pain management unit can benefit markedly from a well-planned documentation system for administrative and scientific purposes. This article presents the principles of such a computerized system based on relational data base programs. The described system has been used by the authors for the last seven years. The successful documentation of more than 1400 patients over treatment periods of up to 2 years has provided detailed administrative and scientific information.

Algorithms↗
PubMed2002

The helpful patient record system: problem oriented and knowledge based.

In contrast to existing computerized patient record systems, which merely offer static functionality for storage and presentation, a helpful patient record system is a problem-oriented, knowledge-based system which provides the clinician with situation-specific information from the patient record, relevant to the activity within the patient care process. We suggest extending the data model of current patient record systems with (1) knowledge for recognizing and interpreting care situations, (2) knowledge of how clinicians work and what information they need, and (3) means to rank information according to its relevance in a given situation. We present a framework that enables representation of three prerequisite features for a future helpful patient record system: the primary care workflow process, the problem-oriented information model, and means to identify relevant information to the care process and medical decisions.

Artificial Intelligence↗
PubMed2006

Evaluation of laboratory monitoring alerts within a computerized physician order entry system for medication orders.

BACKGROUND: Errors involving medication use are common. Computerized physician order entry (CPOE) can improve prescribing practices. Few studies have examined the effect of CPOE in combination with decision support tools on prescribing practices in the outpatient setting. Less is known about prescribers' adherence to laboratory monitoring recommendations. OBJECTIVE: To evaluate if reminders presented during CPOE for medications would increase physicians' compliance with guidelines for laboratory monitoring at initiation of therapy. STUDY DESIGN: Randomized prospective intervention study. METHODS: Two hundred seven primary care physicians in a group-model managed care organization were randomized to receive or not receive drug laboratory monitoring alerts within the CPOE system. Adherence to laboratory monitoring recommendations for patients prescribed selected medications was compared between physician groups. RESULTS: There was no significant difference between the control and intervention group physicians in the overall rate of compliance with ordering the recommended laboratory monitoring for patients prescribed study medications. Laboratory monitoring was performed as recommended 56.6% of the time in the intervention group compared with 57.1% of the time in the control group (P = .31). In cases in which a statistically significant difference was demonstrated, improved compliance favored the intervention group (eg, 71.2% vs 62.3% [P = .003] for gemfibrozil and 75.7% vs 73.9% [P = .05] for statins). CONCLUSIONS: As CPOE becomes more prevalent, additional research is needed to determine effective decision support tools. These findings then should be communicated to the developers and users of computerized medical record systems.

Adolescent↗
PubMed1998

Problem focused knowledge navigation: implementing the problem focused medical record and the O-HEAP note.

The current organization of most Computerized Medical Records (CMR) is based on the Problem Oriented Medical Record (POMR) and the SOAP (Subjective, Objective, Assessment and Plan) note. The organizational structure of the POMR and especially the SOAP note, does not allow for optimal use of computer capabilities in the follow up note. Since follow up visits are the most common office visit by far, this is a major flaw in the CMR. The authors propose a Problem Focused Medical Record and the OHEAP (Orientation, History, Exam, Assessment and Plan) note to resolve this problem. OHEAP starts with a powerful orientation structure that brings forward the timeline, last Assessment and Plan, and Plan Results for each problem along with the patient's historical tables as the starting point of every follow up visit. The Assessment and Plan portion brings problem specific differential diagnoses and their workups along with other relevant tables such as expert systems, treatments, instructions, medical literature or pathways. This leads to Problem Focused Knowledge Navigation that brings powerful efficiencies to the CMR. By recognizing the true workflow in the longitudinal diagnosis and management of any medical problem, the efficiency of the CMR is maximized. OHEAP allows for optimal use of both personal and external data elements in the medical record. Its powerful orientation attributes minimize the time spent in analyzing the current status of the problem while its connections to problem specific databases help resolve the problem.

Decision Making, Computer-Assisted↗
PubMed2003

An applied evaluation of SNOMED CT as a clinical vocabulary for the computerized diagnosis and problem list.

The use of a standardized controlled terminology allows diverse systems and applications throughout the enterprise to translate data. In developing a customized enterprise-wide vocabulary for clinical terminology, we implemented SNOMED CT as a base vocabulary, while facilitating the addition of site-specific clinical terms or concepts not represented in SNOMED CT. In this paper, we evaluate the breadth of SNOMED CT terms and concepts for the coding of diagnosis and problem lists by clinicians within a computerized physician order entry (CPOE) system. Clinicians selected diagnosis and problem list terms from a lexicon based on SNOMED CT, submitting requests for clinical terms that were not found in the controlled vocabulary. For each "missing" term, we assigned one of four mapping types, representing the relationship of this new terminology entry to the SNOMED CT reference terminology. Our results show that the majority of diagnosis/problem list terms (88.4%) were found in SNOMED CT. Of the 145 missing terms, only 20 represented significant concepts missing from SNOMED CT, resulting in concept coverage of 98.5%. Our results show that SNOMED CT is a relatively complete standardized terminology on which to base a vocabulary for the clinical problem list.

Abbreviations as Topic↗
PubMed2006

Developing a national primary care-based early warning system for health protection--a surveillance tool for the future? Analysis of routinely collected data.

The increasing threat of infections with pandemic potential such as influenza has focussed attention on the information needed to inform those managing a pandemic. The Health Protection Agency, Nottingham University and EMIS have developed a new national health protection surveillance system using QRESEARCH, an established primary care-derived database, to provide timely and local information on trends in community illness and prescribing. This article describes the first year of the surveillance project. Data on consultations and prescribing were extracted from routinely generated computerized consultation records between November 2004 and December 2005. Weekly consultation and prescribing rates for a range of conditions including influenza-like illness and prescription of anti-viral drugs for influenza and vomiting were developed as 'key indicators'. These indicators were presented in a weekly bulletin showing data to strategic health authority level for use by those working in public health. The particular value of this scheme is the ability to produce timely data on illness to local level and to link prescribing to morbidity. The data were used 'real time' to reassure about lack of illness following the Buncefield Fuel Depot incident. This scheme is being further developed to provide daily local influenza-related information needed in an influenza pandemic.

Ambulatory Care Information Systems↗
PubMed1997

The impact of anticipatory patient data displays on physician decision making: a pilot study.

Computerized patient records have long offered the promise of facilitated access to patient data for clinical decision-making. Nonetheless, the decision process benefits of improved patient data access have been poorly quantified by prior informatics research. We conducted a pilot study to test the feasibility of study methods and gather data for the planning of a future clinical trial designed to assess the impact of patient data summary displays on serum lipid test interpretation time, on targeted data retrieval time for related data, and on decision quality. The pilot demonstrated feasibility and high face validity of the decision-making simulation methods used. Problem-focused patient data summaries appear to reduce time-based decision performance measures by 40-50%, and may improve decision quality even without the inclusion of knowledge-based recommendations or guideline representations.

Data Display↗
PubMed2005

Information retrieval performance of probabilistically generated, problem-specific computerized provider order entry pick-lists: a pilot study.

OBJECTIVE: The aim of this study was to preliminarily determine the feasibility of probabilistically generating problem-specific computerized provider order entry (CPOE) pick-lists from a database of explicitly linked orders and problems from actual clinical cases. DESIGN: In a pilot retrospective validation, physicians reviewed internal medicine cases consisting of the admission history and physical examination and orders placed using CPOE during the first 24 hours after admission. They created coded problem lists and linked orders from individual cases to the problem for which they were most indicated. Problem-specific order pick-lists were generated by including a given order in a pick-list if the probability of linkage of order and problem (PLOP) equaled or exceeded a specified threshold. PLOP for a given linked order-problem pair was computed as its prevalence among the other cases in the experiment with the given problem. The orders that the reviewer linked to a given problem instance served as the reference standard to evaluate its system-generated pick-list. MEASUREMENTS: Recall, precision, and length of the pick-lists. RESULTS: Average recall reached a maximum of .67 with a precision of .17 and pick-list length of 31.22 at a PLOP threshold of 0. Average precision reached a maximum of .73 with a recall of .09 and pick-list length of .42 at a PLOP threshold of .9. Recall varied inversely with precision in classic information retrieval behavior. CONCLUSION: We preliminarily conclude that it is feasible to generate problem-specific CPOE pick-lists probabilistically from a database of explicitly linked orders and problems. Further research is necessary to determine the usefulness of this approach in real-world settings.

Humans↗
PubMed1993

Insurance coverage and residents' experience in a pediatric teaching clinic.

To examine the relationship between insurance coverage and the diagnostic content of residents' experience in a hospital-based pediatric teaching clinic, we analyzed outpatient problem lists for 6543 patients seen in our clinic over a 15-month period. Problem-list contents were categorized using diagnostic clusters. The frequency distribution of clustered problems was compared for patients with four types of insurance coverage: indemnity insurance, health maintenance organization, Medicaid, and no insurance. The four insurance categories differed in the overall distribution of problems, but the differences could not be attributed to a disparity in the frequency of any single diagnosis or diagnostic cluster. We conclude that there was no important effect of insurance coverage on the diagnostic content of residents' experience in a teaching clinic.

Child↗
PubMed1994

User metaphors for health care professional workstations.

The problem encountered by health care professionals and software developers has been a lack of demonstrable visions (prototypes) for Computer-based Patient Record (CPR) and Clinical Information System (CIS) applications. This deficiency has resulted in a quest for and consideration of models, metaphors, and mind maps for the Healthcare Professional Workstation (HPW)--the access mechanism for the CPR and the CIS. The familiar physician desktop and traditional paper-based metaphors are not adequate for all aspects of clinical information processes. In the clinical care environment, the flowsheet is a transporting metaphor because many different applications and tasks can be 'transported' into the flowsheet. 3D Rooms, Gopher and Genes are familiar and transporting metaphors to be exploited for HPWs. Using transporting metaphors for HPW software emphasizes commonality and de-emphasizes diversity. Each model and metaphor has an associated mind map. Only the mental model, mental metaphor or mind map for HPW software is important. Metaphors communicate real-world analogies, and communication is at the core of what defines usability. A mind map facilitates communication by building a model in the user's mind. The barriers to HPWs are not technical; they are related to economics, ownership of patient information, liability and information standards.

Computer Systems↗
PubMed2005

Leveraging systems thinking to design patient-centered clinical documentation systems.

A hospital is a type of system, yet healthcare information technology (IT) has largely failed to view it as such. The failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation. This paper seeks to address how current clinical documentation practices reflect and reinforce inefficiency and poor patient care. It also addresses how rethinking clinical documentation and IT together may improve the entire healthcare process by promoting a more integrated and patient-centered healthcare information paradigm. Rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication.

Efficiency, Organizational↗
PubMed2005

Natural language processing to extract medical problems from electronic clinical documents: performance evaluation.

In this study, we evaluate the performance of a Natural Language Processing (NLP) application designed to extract medical problems from narrative text clinical documents. The documents come from a patient's electronic medical record and medical problems are proposed for inclusion in the patient's electronic problem list. This application has been developed to help maintain the problem list and make it more accurate, complete, and up-to-date. The NLP part of this system-analyzed in this study-uses the UMLS MetaMap Transfer (MMTx) application and a negation detection algorithm called NegEx to extract 80 different medical problems selected for their frequency of use in our institution. When using MMTx with its default data set, we measured a recall of 0.74 and a precision of 0.756. A custom data subset for MMTx was created, making it faster and significantly improving the recall to 0.896 with a non-significant reduction in precision.

Algorithms↗
PubMed2006

Representation of ophthalmology concepts by electronic systems: intercoder agreement among physicians using controlled terminologies.

OBJECTIVE: To assess intercoder agreement for ophthalmology concepts by 3 physician coders using 5 controlled terminologies (International Classification of Diseases 9, Clinical Modification [ICD9CM]; Current Procedural Terminology, fourth edition; Logical Observation Identifiers, Names, and Codes [LOINC]; Systematized Nomenclature of Medicine, Clinical Terms [SNOMED-CT]; and Medical Entities Dictionary). DESIGN: Noncomparative case series. PARTICIPANTS: Five complete ophthalmology case presentations selected from a publicly available journal. METHODS: Each case was parsed into discrete concepts. Electronic or paper browsers were used independently by 3 physician coders to assign a code for every concept in each terminology. A match score representing adequacy of assignment for each concept was assigned on a 3-point scale (0, no match; 1, partial match; 2, complete match). For every concept, the level of intercoder agreement was determined by 2 methods: (1) based on exact code matching with assignment of complete agreement when all coders assigned the same code, partial agreement when 2 coders assigned the same code, and no agreement when all coders assigned different codes, and (2) based on manual review for semantic equivalence of all assigned codes by an independent ophthalmologist to classify intercoder agreement for each concept as complete agreement, partial agreement, or no agreement. Subsequently, intercoder agreement was calculated in the same manner for the subset of concepts judged to have adequate coverage by each terminology, based on receiving a match score of 2 by at least 2 of the 3 coders. MAIN OUTCOME MEASURES: Intercoder agreement in each controlled terminology: complete, partial, or none. RESULTS: Cases were parsed into 242 unique concepts. When all concepts were analyzed by manual review, the proportion of complete intercoder agreement ranged from 12% (LOINC) to 44% (SNOMED-CT), and the difference in intercoder agreement between LOINC and all other terminologies was statistically significant (P<0.004). When only concepts with adequate terminology were analyzed by manual review, the proportion of complete intercoder agreement ranged from 33% (LOINC) to 64% (ICD9CM), and there were no statistically significant differences in intercoder agreement among any pairs of terminologies. CONCLUSIONS: The level of intercoder agreement for ophthalmic concepts in existing controlled medical terminologies is imperfect. Intercoder reproducibility is essential for accurate and consistent electronic representation of medical data.

Decision Support Systems, Clinical↗
PubMed2005

Quality and variability of osteoporosis data in general practice computer records: implications for disease registers.

OBJECTIVE: To determine the extent to which routinely collected general practitioner computer data could be used to create disease registers of patients with osteoporosis, and to report any improvement in data quality since previous studies. STUDY DESIGN: Audit using anonymized data extracted from general practice computer records from across England. METHODS: Morbidity Query Information and Export Syntax (MIQUEST) software was used to extract structured data from the 78 volunteer practices that participated in the study. The data were aggregated and analysed. RESULTS: There were 100-fold differences in the rates of recording of relevant data. Many patients receiving treatment had no diagnostic codes. Data about secondary causes of osteoporosis and fractures were more consistently recorded than data relating to falls. There were no data to indicate whether fractures were low impact. T-scores, the gold-standard measure of bone density, were very infrequently recorded. CONCLUSIONS: Sufficient data about secondary causes of osteoporosis exist, and these could be searched to identify patients at risk. Meanwhile, fracture recoding could be improved, including likely fragility fractures, and T-scores could be added to computer records. A systematic approach is needed to raise the computer records to a standard where they can be used as valid and reliable disease registers.

Accidental Falls↗
PubMed2004

Shedding our illusions: a better way of medicine.

Caregivers are constantly trying to organize their collective efforts in a way that serves the needs of individual patients. And patients themselves seek active involvement and control in their own care. Disorder in medical practice frustrates achievement of all of these goals. Escaping that disorder requires using information tools designed for two purposes: (A) combining patient data with medical knowledge more effectively than the unaided human mind permits, and (B) organizing the multiple processes involved in patient care.

Humans↗
PubMed1999

New approach to the medical information system for quality management in patient care: development of Problem Mapping System.

A new type of medical information system named Problem Mapping System (P-Map) has been developed, which aids physicians with solving patients' problems. With this system, physicians can define the problems of in-patients, monitor their progress clearly, and share information efficiently. In P-map, a list of problems, such as disease names, can be set for each inpatient easily. The progress of each problem is clearly shown using progress lines on a time axis. Physicians can save the Subjective Objective Assessment Plan (SOAP) notes which are linked to each problem. At the final stage of patient care, a discharge summary can be made easily. With the aid of this system, the quality of patient care is improved due to the following: (1) physicians can make the best decision; (2) medical staff in the same team can provide the best medical treatment; (3) evaluation of each medical treatment is easy; (4) saved data can be used effectively for education and research; (5) the system can improve cooperation with other medical institutes by providing discharge summary information which can be distributed using e-mail; and (6) the system can improve patients' understanding for the purpose of informed consent by providing clear and well organized information to patients.

Computer Systems↗
PubMed1993

[Obstetric data processing with a personal computer].

Update computer technology is an increasingly useful tool in medicine for more accurate documentation, avoidance of multiple documentation, improvement of service performance, quicker and easier data processing and evaluation and hence quality assurance. We developed an obstetric data recording programme for an IBM compatible personal computer according to the MS-DOS command programme. A laser printer with dual paper feed is available. The relational database system Clipper is used for programming. The programme comprises at present 179 data fields and is subdivided on the input side into: data on anamnesis and partus, course of puerperium, infant data. This gives the print-outs: birth protocol, adhesive labels for the temperature curves of the mother and of the infant, respectively, birth record book and mother-infant health passport, furthermore, list print-outs: infant record book, transferred/decreased infants, birth lists relating to midwives, and, in addition, physician's report on the mother and the child, and finally, automated monthly and annual statistics. From August 1990 to July 1992, all events were stored by the computer, so that a total of 5,572 data items have been recorded to date. The primary scope of recording was 98.4% already in the first year of full operation of the database. Computer feed-in was affected directly after each data item became available. Application is fully integrated into normal clinical everyday work. To ensure best possible motivation and acceptance, special attention was paid to user friendliness and immediate print-outs whenever required. Attention was also given to the inclusion of infant follow-up data. The computer programme has been accepted for daily operation, and the necessary data quality has been attained by means of proper choice of the appropriate user groups and manifold measures to ensure integration, safe working, continual servicing and creation of suitable working and data feed conditions.

Attitude to Computers↗