Adam Fadlalla

A framework for assessing e-health preparedness

Whilst healthcare is the biggest service industry on the globe, it has yet to realise the full potential of the e-business revolution in the form of e-health. This is due to many reasons including the fact that the healthcare industry is faced with many complex challenges in trying to deliver cost-effective, high-value, accessible healthcare and has traditionally been slow to embrace new business techniques and technologies. Given that e-health, to a great extent, is a macro level concern that has far reaching micro level implications, this paper firstly develops a framework to assess a countrys preparedness with respect to embracing e-health (the application of e-commerce to healthcare) and from this an e-health preparedness grid to facilitate the assessment of any e-health initiative. Taken together, the integrative framework and preparedness grid provide useful and necessary tools to enable successful e-health initiatives to ensue by helping country and/or an organisation within a country to identify and thus address areas that require further attention in order for it to undertake a successful e-health initiative.

A context-based integrative framework for e-government initiatives

Abstract The recent advances in the Internet technology have propelled the development of related applications in electronic communications and transactions, including electronic commerce and electronic government (e-government). There has been a proliferation of e-government initiatives worldwide undertaken under different forms of government, socioeconomic settings, and technological conditions. Nonetheless, the relationship between an e-government initiative and its context has not received adequate attention in the e-government literature. This paper provides an organizing framework that maps the core values (goals) of e-government to two fundamental factors; namely, the degree of e-government readiness and the level of democratization. The framework addresses the importance of the relationship between the context within which e-government initiatives are undertaken and the goals of those initiatives. From a conceptual perspective, this framework underscores the pivotal importance of the context of an e-government initiative in influencing the goals of this initiative. From a practical viewpoint, the framework provides a roadmap for policy makers to formulate policy goals of e-government initiatives commensurate with their respective environments.

Fever and Leukocytosis in Critically Ill Trauma Patients: It's Not the Urine*

BACKGROUND Infectious complications are a major cause of morbidity and mortality in critically ill trauma patients. Therefore, fever and leukocytosis often trigger an extensive laboratory workup that includes a urine culture (UCx). The purposes of this study were to: 1) Define the current practice for obtaining UCxs in trauma patients admitted to the surgical and trauma intensive care unit (STICU); and 2) determine if there is an association between fever or leukocytosis and urinary tract infections (UTIs) during the initial 14 hospital days. METHODS An 18-month retrospective cohort analysis was performed on consecutive trauma patients admitted for at least two days to the STICU at a level I trauma center. Data collected included demographics, injuries, and daily maximal temperature (T(max)), leukocyte count, and UCx results for the first 14 days. Fever and leukocytosis were defined as T(max) > or =38.5 degrees C and leukocyte count > or =12,000/mm(3), respectively. Urinary tract infections were diagnosed with a positive UCx (> or =10(5) organisms/mL of urine). RESULTS Five hundred ten patients were evaluated for a total of 3,839 patient-days. Their mean age and Injury Severity Score were 49 +/- 1 years and 19 +/- 1 points, respectively. Seventy-two percent were men, and 91% had sustained blunt injuries. Four hundred seven UCxs were obtained; 42 patients (8%) had 60 UTIs. The cohort had an indwelling urinary catheter for 97% of the patient-days, yielding an infection density of 16 UTIs/1,000 urinary catheter-days. There was a significant association between obtaining a UCx and fever and between fever and leukocytosis (both, p < 0.001), but no association of UTI with fever, leukocytosis, or the combination of fever and leukocytosis. Analysis using temperature and leukocyte count as continuous variables identified no temperature or leukocyte range associated with UTIs. Independent risk factors for UTI calculated by logistic regression were female sex, older age, low Injury Severity Score, and no antibiotics within 24 h before the UCx was obtained. CONCLUSIONS The practice of obtaining a UCx from the STICU trauma patient was related to fever and fever with leukocytosis. However, neither fever nor leukocytosis nor both were associated with UTIs. These data suggest that there is an unnecessary emphasis on UTI as a source of fever and leukocytosis in injured patients during their first 14 STICU days. Our results suggest that the paradigm for evaluating UTI as a cause of fever needs to be reevaluated in critically ill trauma patients.

Data Warehouse Administration and Management

Abstract Data warehouses are huge repositories of legacy data. They are usually configured as stars or snowflakes, and their application strength is their ability to associate pieces of data in unique and multiple ways. Obviously, they are very different from traditional relational databases, and as such they require administrators that possess a skill set different from that of traditional database administrators. This article explores the skills a data warehouse administrator must possess.

Validation of Surgical Intensive Care-Infection Registry: a medical informatics system for intensive care unit research, quality of care improvement, and daily patient care.

BACKGROUND We developed a prototype electronic clinical information system called the Surgical Intensive Care-Infection Registry (SIC-IR) to prospectively study infectious complications and monitor quality of care improvement programs in the surgical and trauma intensive care unit. The objective of this study was to validate SIC-IR as a successful health information technology with an accurate clinical data repository. STUDY DESIGN Using the DeLone and McLean Model of Information Systems Success as a framework, we evaluated SIC-IR in a 3-month prospective crossover study of physician use in one of our two surgical and trauma intensive care units (SIC-IR unit versus non SIC-IR unit). Three simultaneous research methodologies were used: a user survey study, a pair of time-motion studies, and an accuracy study of SIC-IRs clinical data repository. RESULTS The SIC-IR user survey results were positive for system reliability, graphic user interface, efficiency, and overall benefit to patient care. There was a significant decrease in prerounding time of nearly 4 minutes per patient on the SIC-IR unit compared with the non SIC-IR unit. The SIC-IR documentation and data archiving was accurate 74% to 100% of the time depending on the data entry method used. This accuracy was significantly improved compared with normal hand-written documentation on the non SIC-IR unit. CONCLUSIONS SIC-IR proved to be a useful application both at individual user and organizational levels and will serve as an accurate tool to conduct prospective research and monitor quality of care improvement programs.

An experimental investigation of the impact of aggregation on the performance of data mining with logistic regression

We studied the impact of data aggregation on the performance of logistic regression on predicting the direction of the Dow Jones industrial average (DJIA) stock market index. Data aggregation is a common operation in business, science, engineering, medicine, etc.; it is performed for purposes such as statistical, financial, and sales and marketing analysis - particularly within the context of a data warehouse. We showed experimentally that, for this example, as long as aggregation does not shrink the sample size unduly, it does not significantly impair the performance of the logistic regression model for predicting the direction of the DJIA stock market index. We also observed that aggregation-based models are simpler (less over-parameterized) than detail-based models. We used the receiver operating characteristic (ROC) analysis to evaluate the robustness of such predictive models. Specifically, we used the area under the ROC curve as a summary measure of the overall performance of a given model.

The Surgical Intensive Care-infection Registry: a research registry with daily clinical support capabilities.

Infections in the surgical and trauma intensive care unit (STICU) are responsible for significant patient morbidity and mortality. Research into these infectious complications often uses administrative databases or clinical information systems designed for documenting and billing daily patient care. Neither of these sources is intended for research, and many investigators have questioned their accuracy. The Surgical Intensive Care–Infection Registry (SIC-IR) was developed as a research data repository to use to monitor STICU infections. SIC-IR is a relational database application designed to collect quality data and to integrate with daily patient care. SIC-IR prospectively collects and archives more than 100 clinical variables daily on each STICU patient to ensure completeness and correctness of the registry. Furthermore, SIC-IR aids in clinical activities by providing patient summaries and medical record documentation. SIC-IR provides accurate data for STICU infection research and enables the users to easily undertake quality-of-care improvement initiatives. (Am J Med Qual 2009;24:29-34)

Integration of Text, Image, and Graphic Data From Different Sources in Laboratory Reports Example of Kidney Stone Reporting System

Laboratory analyses may generate multiple data types that may reside in disparate systems, and combining data into a report often requires laborious, error-prone methods. Kidney stone analysis, which includes biochemical composition analysis and gross feature documentation, is an example of such a situation. We developed the kidney stone reporting system (KISS) that integrates patient and specimen information from the laboratory information system, digital images of stones, and analytic instrument data into a concise report for the ordering clinicians. The database management environment facilitates archival and retrieval capabilities. Implementation of the system has reduced the number of manual steps necessary to produce a report and has saved approximately 30 technologist hours per week. Transcription errors have been virtually eliminated. The KISS represents an innovative use of standard tools to integrate text, image, and graphic data from disparate systems into an integrated laboratory report, without the need for expensive interfaces.

Who is monitoring your infections: shouldn't you be?

BACKGROUND In the era of pay for performance and outcome comparisons among institutions, it is imperative to have reliable and accurate surveillance methodology for monitoring infectious complications. The current monitoring standard often involves a combination of prospective and retrospective analysis by trained infection control (IC) teams. We have developed a medical informatics application, the Surgical Intensive Care-Infection Registry (SIC-IR), to assist with infection surveillance. The objectives of this study were to: (1) Evaluate for differences in data gathered between the current IC practices and SIC-IR; and (2) determine which method has the best sensitivity and specificity for identifying ventilator-associated pneumonia (VAP). METHODS A prospective analysis was conducted in two surgical and trauma intensive care units (STICU) at a level I trauma center (Unit 1: 8 months, Unit 2: 4 months). Data were collected simultaneously by the SIC-IR system at the point of patient care and by IC utilizing multiple administrative and clinical modalities. Data collected by both systems included patient days, ventilator days, central line days, number of VAPs, and number of catheter-related blood steam infections (CR-BSIs). Both VAPs and CR-BSIs were classified using the definitions of the U.S. Centers for Disease Control and Prevention. The VAPs were analyzed individually, and true infections were defined by a physician panel blinded to methodology of surveillance. Using these true infections as a reference standard, sensitivity and specificity for both SIC-IR and IC were determined. RESULTS A total of 769 patients were evaluated by both surveillance systems. There were statistical differences between the median number of patient days/month and ventilator-days/month when IC was compared with SIC-IR. There was no difference in the rates of CR-BSI/1,000 central line days per month. However, VAP rates were significantly different for the two surveillance methodologies (SIC-IR: 14.8/1,000 ventilator days, IC: 8.4/1,000 ventilator days; p = 0.008). The physician panel identified 40 patients (5%) who had 43 VAPs. The SIC-IR identified 39 and IC documented 22 of the 40 patients with VAP. The SIC-IR had a sensitivity and specificity of 97% and 100%, respectively, for identifying VAP and for IC, a sensitivity of 56% and a specificity of 99%. CONCLUSIONS Utilizing SIC-IR at the point of patient care by a multidisciplinary STICU team offers more accurate infection surveillance with high sensitivity and specificity. This monitoring can be accomplished without additional resources and engages the physicians treating the patient.

Critical Analysis of Empiric Antibiotic Utilization: Establishing Benchmarks

AIM We critically evaluated empiric antibiotic practice in the surgical and trauma intensive care unit (STICU) with three specific objectives: (1) To characterize empiric antibiotics practice prospectively; (2) to determine how frequently STICU patients started on empiric antibiotics subsequently have a confirmed infection; and (3) to elucidate the complications associated with unnecessary empiric antibiotic therapy. METHODS We collected data prospectively using the Surgical Intensive Care-Infection Registry (SIC-IR) including all 1,185 patients admitted to the STICU for >2 days from March 2007 through May 2008. Empiric antibiotics were defined as those initiated because of suspected infections. RESULTS The mean patient age was 56 years and 62% were male. The mean STICU length of stay was eight days, and the mortality rate was 4.6%. Empiric antibiotics were started for 26.3% of the patients. The average length of antibiotic use was three days. Of the 312 patients started on empiric antibiotics, only 25.6% were found to have an infection. Factors associated with correctly starting empiric antibiotics were a longer STICU stay (5 vs. 3 days), prior antibiotics (29% vs. 17%), and mechanical ventilation (93% vs. 79%). Patients who were started on antibiotics without a subsequent confirmed infection were compared with patients not given empiric antibiotics. Incorrect use of empiric antibiotics was associated with younger age (p < 0.001), more STICU days (10.6 vs. 5.9 days; p < 0.001), more ventilator days (p < 0.001), more development of acute renal failure (24.1% vs. 12.1%; p < 0.001), and a significant difference in mortality rate (8.6% vs. 3.2%; p < 0.001). CONCLUSIONS After admission to the STICU, 26% of patients received at least one course of empiric antibiotics. Only 25.6% of these patients were confirmed to have an infection. These results provide key benchmark data for the critical care community to improve antibiotic stewardship.