Charles Safran

Guidelines for management of HIV infection with computer-based patient's record

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.

Predicting in-hospital mortality. The importance of functional status information.

Monitoring risk-adjusted outcomes is the centerpiece of efforts to ensure health care quality. Because data collection is expensive, questions arise concerning what information is essential to adjust for risk. This investigation used retrospective analysis of existing, computerized clinical databases containing laboratory test results, information on chronic coexisting conditions, and nursing evaluations of functional status to predict in-hospital mortality. We studied persons admitted to one tertiary teaching hospital between 1987 and 1992 for cerebrovascular disease or pneumonia. Predictive models for each of the conditions were developed using logistic regression; the results were validated with split samples. We compared the predictive value of the nursing functional status assessments and the clinical laboratory data. For each study condition, the functional status data had as much prognostic information as the laboratory data. Specifically, a nurses report that a patient required total assistance for bathing was the best single predictor of in-hospital mortality in the models for patients with either cerebrovascular disease or pneumonia. If hospitals admit patients with different levels of functional impairment, it is important to account for these differences before comparing outcomes across facilities. Assessments of functional status are a simple, inexpensive measure that may have considerable value.

The Collaborative Health Care Team: The Role of Individual and Group Expertise

Background: Increasing costs of health care and rapid knowledge growth have led to collaboration among health care professionals to share knowledge and skills. Purposes: To characterize the qualitative nature of team interaction and its relation to training health professionals, drawing on theoretical and analytical frameworks from the sociocognitive sciences. Methods: Activities in a primary care unit were monitored using observational field notes, hospital documents, and audio recordings of interviews and clinical interactions. Results: The demarcation of responsibilities and roles of personnel within the team became fuzzy in practice. Continuous care was provided by primary care providers and specialized care by intermittent consultants. The nature of individual expertise required was a function of the patient problem and the interaction goal. These team characteristics contributed to the reduction of unnecessary and redundant interactions. Conclusions: Distributed responsibilities allow the team to process massive amounts of patient information, reducing the cognitive load on individuals. The uniqueness of individual professional expertise as it contributes to the accomplishment of team goals is highlighted, suggesting emphasis on conceptual competence in the development of individual professional education programs.

Identification of factors associated with the diagnosis of delirium in elderly hospitalized patients.

We analyzed factors associated with the discharge diagnosis of delirium among 1,285 patients admitted to a major teaching hospital during a 2‐year period, developed a model to classify the risk of developing delirium on the basis of clinical and diagnostic data, and tested the model on 471 patients admitted during the subsequent year. Using the multivariate technique of recursive partitioning, we identified four factors that distinguished 80% of all cases of delirium: 1) a urinary tract infection at any time during the hospital stay (odds ratio = 3.1; 95% confidence interval = 2.02–4.58); 2) no urinary tract infection, but low serum albumin on admission (odds ratio = 2.4; 95% confidence interval = 1.43–3.99); 3) neither urinary tract infection nor low serum albumin, but elevated white blood cell count on admission (odds ratio = 1.99; 95% confidence interval = 1.18‐3.37); 4) none of these risk factors, but proteinuria on admission (odds ratio = 1.82; 95% confidence interval = 2.25–2.66). Patients without any of these four risk factors had the lowest probability of developing delirium during their hospital stay. Among individuals with delirium, in‐hospital mortality and hospital charges were higher. The model developed accurately characterized the risk of delirium when it was tested on patients admitted to the same hospital during the subsequent year.

The collaborative edge: patient empowerment for vulnerable populations

OBJECTIVE The problems with access to care and the special needs for educational outreach for disadvantage or vulnerable populations of patients require innovation. This paper describes Baby CareLink use of information technology to support communication, consultation, and collaboration among colleagues as well as with patients, their families, and community resources. METHODS In response to the educational, emotional and communication needs of parents of premature infants and the clinicians who care for the infants and support the families, we developed Baby CareLink, a secure collaborative environment. Baby CareLink provides a nurturing environment where parents, even though remote from the Neonatal Intensive Care Unit, can actively participate in decisions surrounding their babys care. RESULTS In a southeastern hospital serving a mostly Medicaid population in a rural setting, more than 300 parents have used Baby CareLink more than 11000 times during the past year. Despite the common wisdom that Medicaid families do not have access to the Internet, approximately 85% of the parents access Baby CareLink from home, at work, from the library or other public access point. The median use of Baby CareLinks from outside the hospital by parents is 17 separate sessions. In a city hospital in the midwestern US which exclusively serves a Medicaid population, experience has been equally encouraging. More than 70 parents have initiated more than 600 secure sessions with Baby CareLink. In contrast to the rural hospital, only 35% of sessions have been initiated outside the hospital. DISCUSSION Experience with Baby CareLink suggests that families from all walks of life will use and benefit from collaborative tools that keep them informed and involved in the care of their children. The most significant barrier to wider deployment is bandwidth limitations into the homes of most families. The care of premature infants is a great example of an area where medical knowledge and ability has grown dramatically, and where information and communication technology holds enormous potential.

Improving personal health records for patient-centered care

OBJECTIVE To assess the patient-centeredness of personal health records (PHR) and offer recommendations for best practice guidelines. DESIGN Semi-structured interviews were conducted in seven large early PHR adopter organizations in 2007. Organizations were purposively selected to represent a variety of US settings, including medium and large hospitals, ambulatory care facilities, insurers and health plans, government departments, and commercial sectors. MEASUREMENTS Patient-centeredness was assessed against a framework of care that includes: (1) respect for patient values, preferences, and expressed needs; (2) information and education; (3) access to care; (4) emotional support to relieve fear and anxiety; (5) involvement of family and friends; (6) continuity and secure transition between healthcare providers; (7) physical comfort; (8) coordination of care. Within this framework we used evidence for patient preferences (where it exists) to compare existing PHR policies, and propose a best practice model. RESULTS Most organizations enable many patient-centered functions such as data access for proxies and minors. No organization allows patient views of clinical progress notes, and turnaround times for PHR reporting of normal laboratory results can be up to 7 days. CONCLUSION Findings suggest patient-centeredness for personal health records can be improved, and recommendations are made for best practice guidelines.

Health care in the information society

The article by Haux and colleagues provides a road map for the use of modern information and communication technology (ICT) in clinical medicine in the next decade. This work is a must-read for all concerned with health policy, health economics, healthcare administration, healthcare information systems, medical informatics and patient care. Haux and his co-workers have 30 theses with associated predictions. These predictions are important both because of what they envision happening and what they predict will not happen. The forecasts are far-reaching and, even if only 20% prove true, profound. Although their predictions are based on their experience in Germany, I believe most readers and students of the field will agree that their ideas generalize across cultures and continents. Certainly, many of their theses and predictions seem plausible in the context of clinical computing within the USA. I find the business of predicting the future a curious process. This is perhaps related to my limited understanding of chaos theory. About a decade ago, I ran a continuing medical education course at Harvard Medical School called Clinical Computing in Patient Care. I had ten outside faculty members who many might feel represented the ‘Who’s Who’ of medical informatics in the USA. I took a poll among them to ascertain when these experts thought 50% of American physicians would be using electronic patient records. All ten agreed that by the year 2000, this milestone would be surpassed. The experts were wrong. Of course, Haux predicts only 10% of hospital-based physicians will have access to full online documentation by the year 2013. But students of chaos theory know that unpredictable events upset dynamic equilibrium in unpredictable ways. Although Haux formulated his ideas before 11 September, 2001, who could have predicted that those events would have profound effects on such issues as ICT in healthcare? The threat of bio-terrorism has fueled the national psyche and medical informatics experts are first in line to help with homeland security (and, by the way, to try to fund infrastructure projects that we have advocated for nearly two decades). What better way to detect a biological attack than to have emergency room surveillance systems and fully functional electronic patient records? Although Haux could have not anticipated this unfortunate change in the world climate, I do feel he and his colleagues have been too * Tel.: /1-617-614-2600x123; fax: /1-617-614-2525 E-mail address: csafran@harvard.edu (C. Safran). International Journal of Medical Informatics 66 (2002) 23 /24

Electronic patient records and the impact of the Internet

The term electronic patient record (EPR) means the electronic collection of clinical narrative and diagnostic reports specific to an individual patient. A true EPR should allow physicians and nurses to practice in a paperless fashion. The wide adoption of Internet technologies should allow truly distributed sharing of patient data across traditional organizational barriers. Hence, the meaning of an EPR, as a representation of documents, should be transformed into a collaborative environment that supports workflow, enables new care models and allows secure access to distributed health data. This paper reviews the current realization of EPRs in the context of paper-based medical records. The Internet architecture that Boston-based medical informatics researchers refer to as W3-EMRS is described in the context of a successful implementation of CareWeb at the Beth Israel Deaconess Medical center. Finally, we describe how this Internet-based approach can be extended beyond the boundaries of traditional care settings to help evolve new collaborative models of eHealth.

Psychological predictors of subsequent medical care among patients hospitalized with cardiac disease.

BACKGROUND There have been numerous reports indicating a relation between psychological distress and coronary artery disease. The authors tried to determine whether psychological distress in patients hospitalized for coronary artery disease is associated with the amount of medical care required after discharge. METHODS Using a prospective clinical cohort, 210 patients who had been admitted for myocardial infarction (n = 67), percutaneous transluminal coronary angioplasty (n = 75), or coronary artery bypass grafting (n = 68) were followed for 6 months. Index psychological status was determined from questionnaires measuring depression and anxiety. Disease severity was assessed by the index hospitalization medical record of left ventricular ejection fraction, number of stenotic vessels, and number of noncardiac comorbidities. The amount of subsequent medical care delivered was based on the number of days of rehospitalization for cardiac-related illness and for any reason within 6 months after discharge. This was determined from a combination of computer medical record and patient self-report. RESULTS The authors first determined that both psychological depression and disease severity each predicted days of rehospitalization. (Anxiety was not predictive of rehospitalization.) Next, disease severity was controlled for using partial correlation, and depression was still predictive of rehospitalization. Finally, the authors combined the predictor variables using a regression model to predict rehospitalization. Depression was a significant main effect in all models predicting rehospitalization. CONCLUSIONS Psychological depression appears to be an important predictor of rehospitalization among persons who have been admitted with coronary artery disease.

ClinQuery: A System for Online Searching of Data in a Teaching Hospital

We designed a user-friendly computer program that permits physicians to search the clinical database of Bostons 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 patients complete medical record for further study. Over a 30-month period, 530 doctors, nurses, medical students, and administrators used the program to search the hospitals 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.