Extensive psoriasis in 1,308 patients has been treated two or three times a week with oral 8-methoxypsoralen followed by high intensity, long-wave ultraviolet light (PUVA). Excluding 169 patients still under early treatment, psoriasis cleared in 88% and failed to clear in 3%. One percent dropped out due to complications of treatment, and 8% for other reasons. The twice-a-week schedule was superior for patients with lighter skin types. Once a remission was induced, there was no difference in its maintenance when patients were treated once a week, once every other week, or once every third week. Each of these schedules was superior to no maintenance treatment. Immediate side effects of the 45,000 treatments administered in the first 18 months of this study were uncommon, temporary, and generally mild. No clinically significant changes in laboratory screening or eye examinations attributable to PUVA have been uncovered.
We designed a user-friendly computer program that permits physicians to search the clinical database of Boston's Beth Israel Hospital by clinical and demographic descriptors. For example, the user can identify all admissions in which diabetic ketoacidosis was diagnosed, the serum bicarbonate level was under 12 mmol/L, and the length of stay exceeded 7 days. Once particular admissions are identified, all data stored in the computerized record can be displayed. Authorized persons can also request the patient's complete medical record for further study. Over a 30-month period, 530 doctors, nurses, medical students, and administrators used the program to search the hospital's clinical database 1786 times. They displayed detailed information on 30,851 patients and requested the complete medical record 5319 times. In 1389 of the 1786 searches completed, the searcher responded to a computer-based questionnaire about motivation for the search. Responses indicated that 32% of the searches were for clinical research, 17% for patient care, 17% for teaching and education, 11% for hospital administration, and 12% for general exploration. In 58% of the searches, respondents indicated definite or probable success in finding the desired information. We conclude that physicians and allied personnel will repeatedly obtain, view, and analyze aggregate clinical information if they are provided with appropriate tools. We believe that such access to clinical information is an important resource for patient care, teaching, and clinical research.
This report describes the departmental and laboratory use of integrated, hospital-wide computing systems at Beth Israel and Brigham and Women's hospitals in Boston. The systems have an important role in the admitting, outpatient, and medical records departments; in the clinical departments (blood bank, cardiology, neurophysiology, pathology, radiology, and pharmacy); in the clinical laboratories; and at Brigham and Women's Hospital, in the financial departments. Information that is collected in the computers from these departments and laboratories is available for viewing by clinicians at terminals located throughout each hospital and is used in compiling charges for each patient's account. The programs are heavily used. During a one-week study period, 742 departmental and laboratory workers at Beth Israel Hospital filed or edited information in patients' computerized records 137,526 times. During the same week, 984 departmental and laboratory workers at Brigham and Women's Hospital filed or edited information 293,367 times. After the computing systems were introduced, the time required to collect unpaid bills decreased substantially at both hospitals.
A comparison of five major categories of stroke in 651 patients revealed significant differences in the frequencies of diagnoses at the Beth Israel and Massachusetts General hospitals in Boston, Mass. (P less than 0.001 by chi-square test). To analyze these differences, we modeled the diagnostic process at each hospital with a Bayesian procedure and performed a crossover study in which each patient was rediagnosed by the model from the opposite hospital. The results indicate that the differences in the frequency of lacune and subarachnoid hemorrhage were associated with the patient population, whereas the differences in the frequency of embolism and atherothrombosis were associated with the diagnostic process. There was a marked difference in the use of arteriograms on the two stroke services, but no difference in morbidity or mortality. The modeling procedure described can be used to compare clinical processes when the allocation of patients is thought to be biased.
This report describes two hospital-wide clinical computing systems that assist physicians, nurses, medical students, and other clinicians in the care of their patients. From any of the video-display terminals located throughout the hospitals (666 at Beth Israel Hospital and 1250 at Brigham and Women's Hospital, both in Boston), clinicians can obtain results from the clinical laboratories; read diagnostic reports from the clinical departments; view lists of medications used during hospitalization and prescriptions filled in the outpatient pharmacy; request delivery of a patient's chart; request consultation on approaches to therapy; perform bibliographic retrieval of the MEDLINE database; and read, write, retract, edit, and forward electronic mail. During a one-week study period, 1737 clinicians at Beth Israel Hospital used one or more of the options in the clinical information system 58,757 times. During the same week, 2262 clinicians at Brigham and Women's Hospital used one or more of their options 89,101 times. The large amount of use by clinicians, who could, if they so desired, rely on printed reports or telephone calls to obtain their clinical information, suggests that a reliable, comprehensive, and easy-to-use computer system can contribute substantially to the quality of patient care.
The time required for 458 women volunteers to respond to questions in a computer-based medical interview was related both to their age and to their formal education. When the analysis was restricted to the 220 women with a college degree, older women responded more slowly than their younger counterparts, and when the analysis was restricted to the 265 women between 18 and 30 years of age, women with less formal education took longer to respond. By contrast, the time required for the volunteers to record their responses was related only to age.
Colleague and PaperChase are the two most widely used computer systems designed specifically for clinicians and scientists who wish to search the National Library of Medicine's MEDLINE data base of references to the biomedical literature. The present study compares the performance of these two systems. Two matched groups of second-year medical students each received 3 hr of instruction, one group in Colleague, the other in PaperChase. Each student then attempted 10 test searches. The next day the groups were reversed, and each student attempted 5 additional searches. During 3 1/2 hr allocated for searching, users of Colleague attempted 64 test searches and retrieved 326 target references; users of PaperChase attempted 78 searches and retrieved 496. Users of Colleague took a mean of 2.2 min and spent a mean of $1.20 to find each target reference; users of PaperChase took 1.6 min and spent $0.92. We conclude that after limited training, medical students find more references faster and at lower cost with PaperChase than with Colleague.
PaperChase is a computer program that permits any physician or scientist to search the National Library of Medicine's MEDLINE data base of references to the biomedical literature. Written for the clinician rather than for the search librarian, PaperChase permits the user to search the entire MEDLINE collection of over 5,000,000 references published in 4,000 biomedical journals dating back to 1966. PaperChase is now available throughout the world to anyone who has a computer terminal or personal computer, and a modem. No special training is needed for a successful search. There is no user's manual. Users can search by title word, Medical Subject Heading, author's name, journal title, year of publication, language of publication, or any combination of the above. Users can read abstracts online, and they can request that a photocopy of the full text of any article be mailed to them.
Seven years ago physicians at the Beth Israel Hospital in Boston began doing their own searches of the medical literature. They used PaperChase, a computer program written especially for end users rather than for search librarians. The data base was initially limited to the journals shelved in the library of the Beth Israel Hospital, but it has since been expanded to include the entire MEDLINE collection of the National Library of Medicine-nearly 5 million references published in 3,400 biomedical journals dating back to 1966.PaperChase is now available throughout the United States and Canada to anyone who has a computer terminal or personal computer and a modem. No special training is needed for a successful search and there is no user's manual. Users can search by title word, "medical subject heading," author's name, journal title, year of publication, language of publication or any combination of the above. They can read abstracts on line, and they can request that a photocopy of the full text of any article be mailed to them.
Modifications in the preparation of food served in a boarding high school during a 5-week period were successful in decreasing the sodium content of a variety of food products by an average of 51%. Such food was, in general, well accepted. The ratings of specific reduced-sodium food products equaled those of similar products containing "usual" amounts of sodium. Food diaries kept by students gave estimates of total sodium intake comparable with those measured by laboratory analysis of 24-hour food collections. Food diaries collected from an average of 70 volunteers per week indicated that during the reduced-sodium period, the total sodium intake of students, including that from dining hall food, snack food, and food consumed outside the school, decreased from 136 mEq (3 gm sodium, 8 gm salt) to 88 mEq (2 gm sodium, 5 gm salt), a reduction of 35% (p less than .0001). The impact of salt added at the table was very small; the choice and the quantity of foods consumed were the main determinants of sodium intake. The results indicate that foods can be prepared with appreciably less sodium and still be highly acceptable to young people.
This report describes a hospital-wide clinical computing system that permits physicians, nurses, medical students, and other health workers to retrieve data from the clinical laboratories; to look up reports from the departments of radiology and pathology; to look up demographic data and outpatient visits; to look up prescriptions filled in the outpatient pharmacy; to perform bibliographic retrieval of the MEDLINE data base; to read, write, retract, edit, and forward electronic mail; and to request delivery of a patient's chart. During a one-week study period, from 300 video display terminals located throughout the hospital, 818 patient care providers used a common registry of 539,000 patients to look up clinical and laboratory data 16,768 times; 477 other hospital workers used the patient registry 46,579 times. In a separate study of 586 health care providers, 470 (80 per cent) indicated that they used computer terminals "most of the time" to look up laboratory results; in contrast, 48 (8 per cent) preferred printed reports. Of 545 hospital workers, 440 (81 per cent) indicated that the computer terminals definitely or probably made their work more accurate, and 452 (83 per cent) indicated that terminals enabled them to work faster. The large amount of use by clinicians and their judgment that the computer has been so helpful to them suggests that a reliable, comprehensive, and easy-to-use computer system can contribute substantially to the quality of patient care.