We developed an on-line medical record (OMR) and integrated it into a mature hospital information system. The OMR provides a number of information resources for the care of patients infected with the human immuno-deficiency virus (HIV), including drug information, an on-line version of a newsletter on AIDS, an on-line version of a textbook on HIV, and an index of research protocols that actively enrolls patients. As part of an 18-month clinical trial of this system, we monitored the use of the information resources and whether or not the resources were being used at the time of a patient's visit. During 16% of office visits of HIV-infected patients, clinicians viewed some HIV-related information. Forty-four of 70 clinicians looked at drug information (the most popular resource) 347 times (eight times per person). Two thirds of each clinician's use of the information was through a patient's electronic record, and about half of those (or one third of each clinician's use) were at the time of a patient's visit. Use of other information resources was somewhat less, but the proportion of uses during a patient's visit was similar. Because of this high level of use, we conclude that clinicians need information resources at the point of patient care and that the electronic medical record is an ideal medium through which to convey this information to providers.
We define "patient precautions" as a unique group of data that is an essential component of the electronic patient record. Patient precautions include medication allergies, difficult airway precautions, infection control precautions, and advance directives. Any piece of data that is associated with the patient, can affect the management of his or her care, and is relatively static over time (as compared with the patient's medication list and problem list) can be considered a patient precaution. An important property of precautions is that the relevant aspects may be brought to the user's attention at the time a patient care decision must be made. We believe this class of data elements is a unique and important component of the electronic patient record that makes it more valuable than the paper record.
We developed a computer-administered health screening interview for the employees of an urban teaching hospital. The interview is part of the integrated Center for Clinical Computing (CCC) clinical information system used throughout the hospital, and is available on any of 2000 terminals. Conducted in private and with protection of confidentiality, the interview seeks information on medical problems and patterns of living for which behavioral change is considered desirable. In a four-year period ending in May 1994, 1937 employees completed the interview. The results showed that stress and unhappiness were common: 57% of the employees reported high levels of stress, and 42% reported feeling sad, discouraged, or hopeless in the previous month; 6% indicated that life sometimes did not seem worth living. Eighty-six percent of the employees expressed an interest in the health-related programs offered by the hospital: 72% were interested in the fitness center, and 37% in the stress-reduction program. We conclude that if interactive health-promotion programs are easily available, they will be used and appreciated in the work place. The programs can be written to reveal the employees' health concerns and stimulate their interest in promoting their own health.
Computers are steadily being incorporated in clinical practice. We conducted a nonrandomised, controlled, prospective trial of electronic messages designed to enhance adherence to clinical practice guidelines. We studied 126 physicians and nurse practitioners who used electronic medical records when caring for 349 patients with HIV infection in a primary care practice. We analysed the response times of clinicians to the situations that triggered alerts and reminders, the number of ambulatory visits, and hospitalisation. The median response times to 303 alerts in the intervention group and 388 alerts in the control group were 11 and 52 days (p < 0.0001), respectively. The median response time to 432 reminders in the intervention group was 114 days and that for 360 reminders in the control group was over 500 days (p < 0.0001). There was no effect on visits to the primary care practice. There was, however, a significant increase in the rate of visits outside the primary care practice (p = 0.02), which is explained by the increased frequency of visits to ophthalmologists. There were no differences in admission rates (p = 0.47), in admissions for pneumocystosis (p = 0.09), in visits to the emergency ward (p = 0.24), or in survival (p = 0.19). We conclude that the electronic medical record was effective in helping clinicians adhere to practice guidelines.
A careful look at studies of "intelligence" and "aptitude" tests belies the contention that these tests measure heritable attributes. Rather, they are achievement tests that measure learned abilities. When stripped of the aura of "intelligence" and "aptitude" and compared with other indexes of accomplishment, they are poor predictors of future performance. Furthermore, when promulgated as measures of cognitive potential, they are socially harmful, particularly to disadvantaged children.
We describe the development, implementation, and use of a computer-administered patient interview, the Health History Interview, by over 300 new patients in a primary care practice at Boston's Beth Israel Hospital. The interview has been well accepted by patients and rated positively by providers. It electronically captures clinical information directly from patients for use during their initial encounter with a provider. It facilitates aggregate analysis of clinical data for quality improvement efforts, such as aiming preventive medicine interventions at identified problem areas within the clinic. Expectations management has been an important task throughout the project. Increasing use of the interview beyond the 30-40% of new patients who have taken it will require greater communication with patients, greater convenience to patients and providers, and more evidence of the clinical, administrative, and research benefits of the technique. Most important, full implementation will require fundamental changes in physician practice habits and patterns of communication between patients and the health care system, as well as clearly demonstrated cost-benefit improvements through the use of these tools.
To evaluate the confidentiality of the patients' data in the electronic patient records designed by members of the Center for Clinical Computing in Boston, we examined the accessibility of the computer-stored medical records of two groups of patients at Boston's Beth Israel Hospital: celebrities, hospital employees, and their relatives (VIPs) and other patients (non-VIPs). We studied how often authorized clinicians gained access to computer-stored data on the two types of patients and whether look-up patterns differed if the data concerned a VIP. Our results suggest that the measures used to maintain data confidentiality at Beth Israel Hospital are adequate.
A frustrating time for hospitalized patients and their primary care providers is after discharge from the hospital, because of changes in patients' medications. We developed a computer program to improve the discharge process, by providing guidance to the physician writing the prescriptions, offering educational material to the patients, and providing electronic notification of medication changes to the primary care providers. During a one-year clinical evaluation of this system, in which use of the program was voluntary, 1000 patients were discharged through the program. House officers tended to use the program more often for patients who were older and in the hospital longer. Both house officers and primary care physicians found the program extremely useful, and the process took no longer than the manual method of creating discharge medication lists. Patients who were discharged using this program may have had better adherence to medication regimens. We conclude that computer-assisted compilation of a discharge medication list is a useful method for improving the discharge process.
To test the ability of a computer-based interview to detect factors related to the risk of the human immunodeficiency virus (HIV) among potential blood donors, and to determine donor reactions to the use of the computer, we compared the rate of detection of HIV-related factors elicited by the computer interview with the rate elicited by standard American Red Cross procedures (written questionnaires and face-to-face interviews) for assessment of donor suitability. The study was performed at a Red Cross blood donor center and a hospital. A consecutive sample of 294 male and female blood donors 18 to 75 years of age participated in a randomized crossover trial in which the order of the two methods was reversed. Among 272 prospective donors who provided complete data, the computer identified 12 who reported either behavior associated with a risk of acquiring HIV or symptoms compatible with AIDS. None of these 12 was so identified by face-to-face interviews or written questionnaires. Only one used the confidential unit exclusion procedure to prevent use of his donated blood. Tests for antibody to HIV were negative in blood from all 272 subjects. The subjects enjoyed the computer interview and judged it to be more private than the standard method for donor assessment.
BACKGROUND: Hospital computing systems play an important part in the communication of clinical information to physicians. We sought to determine whether computer-based alerts for hospitalized patients can affect physicians' behavior and improve patients' outcomes.
METHODS: We performed a prospective time-series study to determine whether computerized alerts to physicians about rising creatinine levels in hospitalized patients receiving nephrotoxic or renally excreted medications led to more rapid adjustment or discontinuation of those medications, and to determine whether such alerts protected renal function.
RESULTS: Laboratory data were observed for 20,228 hospitalizations, with documentation of 1573 events (instances of rising creatinine levels during treatment with a nephrotoxic or renally excreted drug). During the intervention period, doses were adjusted or medications discontinued an average of 21.6 hours sooner after such an event (P < .0001). For patients receiving nephrotoxic medications during the intervention period, the relative risk of serious renal impairment was 0.45 (95% confidence interval, 0.22 to 0.94) as compared with the control period, and the mean serum creatinine level was 14.1 mumol/L (0.16 mg/dL) lower on day 3 (P < .01) and 25.6 mumol/L (0.29 mg/dL) lower on day 7 (P < .05) after an event. Forty-four percent of physicians who responded to a questionnaire said that the alerts had been helpful in the care of their patients, whereas 28% found them annoying. Sixty-five percent wished to continue receiving alerts.
CONCLUSIONS: Computer-based alerts regarding patients with rising creatinine levels affect physician behavior, prevent serious renal impairment, preserve renal function, and are accepted by clinicians.