James R. Campbell

The SAGE Guideline Model: Achievements and Overview

The SAGE (Standards-Based Active Guideline Environment) project was formed to create a methodology and infrastructure required to demonstrate integration of decision-support technology for guideline-based care in commercial clinical information systems. This paper describes the development and innovative features of the SAGE Guideline Model and reports our experience encoding four guidelines. Innovations include methods for integrating guideline-based decision support with clinical workflow and employment of enterprise order sets. Using SAGE, a clinician informatician can encode computable guideline content as recommendation sets using only standard terminologies and standards-based patient information models. The SAGE Model supports encoding large portions of guideline knowledge as re-usable declarative evidence statements and supports querying external knowledge sources.

Computerized medical records and preventive health care: success depends on many factors.

OBJECTIVE To study the effect of a computerized medical record and other practice factors on the delivery of preventive health care. DESIGN Prospective, controlled trial. SETTING University general internal medicine teaching clinic. PARTICIPANTS Forty-five internal medicine residents and their 4 supervising attending physicians. INTERVENTION The study group used a computerized ambulatory medical record system that included health care maintenance reminders. The control group used a conventional paper record with a health care maintenance flow sheet. MEASUREMENTS AND MAIN RESULTS The computer reminders significantly increased health care maintenance recommendations made to patients for proctosigmoidoscopy, tetanus vaccination, influenza vaccination, and pneumococcal vaccination, but not for fecal occult blood testing, mammography, Pap smears, or serum thyroxine screening in the elderly. First-year residents were nearly twice as successful as third-year residents in overall health care maintenance. Success scores varied markedly depending on which attending physician was supervising the residents. We found a strong interaction among group assignment, supervising attending, and level of training such that the reminders doubled success scores among first-year residents supervised by two of the attending physicians but had little effect on other subgroups. The time of year and the format of the reminder also had important effects for some of the maneuvers. CONCLUSIONS Although computerized medical records markedly improved the performance of prevention maneuvers by committed physicians, many physicians using computer systems failed to make use of the resource. The reasons for this were complex. Future work in this area should carefully control for personal behaviors and focus upon administrative changes that more effectively implement these potentially powerful tools.

Effect of two aspirin pretreatment regimens on niacin-induced cutaneous reactions

ObjectiveTo compare the effects of pretreatment with two aspirin regimens and placebo on niacin-induced cutaneous reactions.DesignRandomized, double-blind, placebo-controlled, crossover study.SettingInternal medicine clinic in an academic health center.ParticipantsForty-two healthy subjects (22 males and 20 females) between the ages of 35 and 65 (mean age 44.2 years) were recruited and completed the study. Subjects received aspirin 325 mg, aspirin 650 mg, and placebo for 4 consecutive days, and on the fourth day also ingested 500 mg of immediate-release niacin 30 minutes after taking aspirin or placebo. They reported the intensity of flushing, headache, pruritus, tingling, and warmth on a 10-cm visual analogue scale. Reactions were evaluated at time 0 (before the niacin, dose), and at 15, 30, 60, and 120 minutes following the niacin dose. Cutaneous reactions were compared at each evaluation time and scored by two other methods. The peak intensity was the highest score recorded at any of the four evaluation times after niacin administration. An intensity-time factor was calculated by totaling the scores of each of the four evaluation times.Measurement and Main ResultsThe symptom scores for flushing, itching, tingling, and warmth were all significantly reduced by both aspirin regimens (p<.05 in all cases), although there were no significant differences between the 325-mg and 650-mg doses. The results were similar for each scoring method.ConclusionsAn aspirin regimen of 325 mg is effective in suppressing niacin-induced cutaneous reactions. Increasing the dose to 650 mg does not provide additional benefit.

Detailed clinical models for sharable, executable guidelines.

The goal of shareable, executable clinical guidelines is both worthwhile and challenging. One of the largest hurdles is that of representing the necessary clinical information in a precise and shareable manner. Standard terminologies and common information models, such as the HL7 RIM, are necessary, they are not sufficient. In addition, common detailed clinical models are needed to give precise semantics and to make the task of mapping between models manageable. We discuss the experience of the SAGE project related to detailed clinical models.

The SAGE guideline modeling: motivation and methodology.

The SAGE (Standards-Based Sharable Active Guideline Environment) project is a collaboration among research groups at six institutions in the US. The ultimate goal of the project is to create an infrastructure that will allow execution of standards-based clinical practice guidelines across heterogeneous clinical information systems. This paper describes the design goals of the SAGE guideline model in the context of the technological infrastructure and guideline modeling methodology that the project is developing.

The Greater Plains Collaborative: a PCORnet Clinical Research Data Network

The Greater Plains Collaborative (GPC) is composed of 10 leading medical centers repurposing the research programs and informatics infrastructures developed through Clinical and Translational Science Award initiatives. Partners are the University of Kansas Medical Center, Childrens Mercy Hospital, University of Iowa Healthcare, the University of Wisconsin-Madison, the Medical College of Wisconsin and Marshfield Clinic, the University of Minnesota Academic Health Center, the University of Nebraska Medical Center, the University of Texas Health Sciences Center at San Antonio, and the University of Texas Southwestern Medical Center. The GPC network brings together a diverse population of 10 million people across 1300 miles covering seven states with a combined area of 679 159 square miles. Using input from community members, breast cancer was selected as a focus for cohort building activities. In addition to a high-prevalence disorder, we also selected a rare disease, amyotrophic lateral sclerosis.

Semantic analysis of SNOMED CT for a post-coordinated database of histopathology findings

Objective This research investigated the use of SNOMED CT to represent diagnostic tissue morphologies and notable tissue architectures typically found within a pathologists microscopic examination report to identify gaps in expressivity of SNOMED CT for use in anatomic pathology. Methods 24 breast biopsy cases were reviewed by two board certified surgical pathologists who independently described the diagnostically important tissue architectures and diagnostic morphologies observed by microscopic examination. In addition, diagnostic comments and details were extracted from the original diagnostic pathology report. 95 unique clinical statements were extracted from 13 malignant and 11 benign breast needle biopsy cases. Results 75% of the inventoried diagnostic terms and statements could be represented by valid SNOMED CT expressions. The expressions included one pre-coordinated expression and 73 post-coordinated expressions. No valid SNOMED CT expressions could be identified or developed to unambiguously assert the meaning of 21 statements (ie, 25% of inventoried clinical statements). Evaluation of the findings indicated that SNOMED CT lacked sufficient definitional expressions or the SNOMED CT concept model prohibited use of certain defined concepts needed to describe the numerous, diagnostically important tissue architectures and morphologic changes found within a surgical pathology microscopic examination. Conclusions Because information gathered during microscopic histopathology examination provides the basis of pathology diagnoses, additional concept definitions for tissue morphometries and modifications to the SNOMED CT concept model are needed and suggested to represent detailed histopathologic findings in computable fashion for purposes of patient information exchange and research. Trial registration number UNMC Institutional Review Board ID# 342-11-EP.

Semantic features of an enterprise interface terminology for SNOMED RT.

OBJECTIVE To evaluate the utility of SNOMED RT in support of a natural language interface for encoding of clinical assessments. METHOD Using a random sample of clinical terms from the UNMC Lexicon, I mapped the terminology into canonical data entries using SNOMED RT. Working from the source term language, I evaluated lexical mapping to the SNOMED term set, and the function of the SNOMED RT semantic network in support of a language-based clinical coding interface. RESULTS Ambiguity in the source terms was low at 0.3%. Lexical (language-based) mapping could account for only 48.8% of meaning from the source terms. The RT semantic network accounted for 39.5% of meaning, and supplementing the lexical map this led to 80.2% capture of source content. Error rates in the segment of RT which I reviewed were low at 0.6%. 97.6% of source content could be accurately captured in SNOMED RT. CONCLUSION SNOMED RT supported an accurate and reliable representation of clinical assessment data in this sample. The semantic network of RT substantially enhanced the encoding of concepts relative to lexical mapping. However these data suggest that natural language encoding with SNOMED RT in an enterprise environment is unlikely at this time.

Semantic interoperation and electronic health records: context sensitive mapping from SNOMED CT to ICD-10.

An important case for successful deployment of a lifetime electronic health record is reuse of clinical data from the electronic health record (EHR) for epidemiology, reimbursement, and research. We report a collaboration between the IHTSDO and the WHO to develop knowledge-based tools supporting translation of data from SNOMED CT to the ICD-10 classification. These tools have been vetted by an international community and are available for system vendors to enhance the interoperability of their products. The maps we created are also informing the development of the next generation of classifications which will employ a common ontology base between SNOMED CT and ICD-11 to promote interoperability.

Blind Comparison of Patient Preference for Flavored Colestid Granules and Questran Light

OBJECTIVE: To compare the sensory and mixability characteristics of Flavored Colestid Granules (a new colestipol formulation) with Questran Light (the most recent cholestyramine formulation). METHODOLOGY: Seventy-two nonsmoking adults between the ages of 25 and 64 years were enrolled in the study. Subjects assessed the sensory and mixability characteristics of each product in chilled bottled water and orange juice after at least a one-hour fast. Products were administered in a double-blind, randomized fashion. The sensory characteristics that were rated included overall rating, aftertaste, appearance, aroma, color, consistency, flavor, sweetness, mouthfeel, and thickness. Each characteristic was rated with a nine-point hedonic scale. Mixability of the products was assessed on a five-point scale. Subjects also were asked to choose which product they preferred as to sensory and mixability characteristics in each vehicle. RESULTS: Fifty-three of the 72 subjects preferred the sensory characteristics of Flavored Colestid Granules in water (p<0.001). Questran Light was preferred by 61 subjects when mixed in orange juice (p<0.001). The sensory characteristic rating scores also supported subject preferences for Flavored Colestid Granules in water and Questran Light in orange juice. Mixability of Flavored Colestid Granules was rated significantly better (p<0.001) than Questran Light in water. There was no significant difference for mixability between the products in orange juice. CONCLUSIONS: Questran Light was significantly preferred on a sensory basis when mixed in orange juice. Flavored Colestid Granules was significantly preferred over Questran Light for both sensory and mixability characteristics with water as the vehicle.