Mary M. Morgan

Quality Assurance through Automated Monitoring and Concurrent Feedback Using a Computer-Based Medical Information System

A computer-based medical information system (COSTAR) has been used to support a quality assurance program where the data collection is an integral part of the patient care recording activity and, therefore, does not require a separate abstracting or encoding process. This program utilizes concurrent audit to detect deficiencies in patient care, and automatic rapid feedback to the responsible provider in time to allow the provider to correct the deficiency. This system has been demonstrated to improve follow-up of throat cultures, positive for Group A Beta hemolytic streptococcus. It is well accepted by the medical staff whose practice is being audited. Because the data are collected as part of the routine operation of COSTAR, the computer monitoring and feedback have only a small incremental cost.

Improving Physician Performance Through Peer Comparison Feedback

A project to improve physician performance in colorectal cancer screening was evaluated as part of an ambulatory quality assurance program. A minimum standard was adopted requiring a digital examination and stool test for occult blood at annual check-ups of patients aged 40 years and older. During a 3½-year period, three different intervention strategies for improved compliance with the standard were sequentially implemented and assessed: educational meeting, retrospective feedback of group compliance rate, and retrospective feedback of individual compliance rate compared with that of peers. A pretest/posttest design was employed in evaluating the first two intervention strategies. Neither strategy resulted in significant improvement in compliance. Monthly feedback of individual performance ranked with that of peers was then implemented in a randomized clinical trial utilizing a crossover design. During the first 6-month period, the physicians receiving feedback (group 1) improved from 66.0% to 79.9% (P <0.001), while the control group (group 2) also improved, from 67.5% to 76.6% (P <0.001), suggesting a spillover effect. During the second 6-month period, group 2 received feedback and group 1 did not. Group 1 stabilized at approximately 80% while group 2 continued to improve from 76.6% to 84.0% (P <0.001). Behavior changes persisted at 6 and 12 months after intervention.

A Computer-Based Monitoring System for Follow-Up of Elevated Blood Pressure

An automated surveillance system utilizing a computer-based medical record system (COSTAR) was designed to improve the follow-up of patients with newly identified elevated diastolic blood pressure. A population of patients was selected where, in the 6-month period following the initial measurement of an elevated diastolic blood pressure, there were fewer than two visits during which blood pressure was recorded. In a randomized controlled clinical trial, this poor follow-up population was divided into two groups, with computer-generated reminders being automatically generated for only patients in the experimental group. Follow-up was significantly improved in the group receiving the reminders, both in terms of rate of follow-up attempted or achieved by the responsible physician and in the repeated recording of blood pressure. We conclude that a computer-based reminder system improves follow-up of newly discovered elevation in diastolic blood pressure.

Conducting a matched-pairs historical Cohort study with a computer-based ambulatory medical record system

We describe techniques for using the Computer-Stored Ambulatory Record (COSTAR) at the Massachusetts General Hospital to conduct a historical cohort study of the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on blood pressure control. A query language was used to identify patients satisfying clinical and data-availability criteria, to match these patients with clinically similar patients not exposed to NSAIDs, and to collect data from the COSTAR records of both groups of patients to determine any differences in outcome. We analyzed over 30,000 patient records to select 90 pairs of patients used in the study. This approach to clinical research uses data collected for purpose of patient care and so does not require the separate recording of patient data for clinical research. Using computer-based medical record systems with a query language allows selection and matching of patients using detailed demographic and clinical criteria. The ability to conduct such studies is an advantage of computer-based medical record systems over the paper record system.

Do resident and staff physicians differ in the types and costs of antihypertensive drugs they select

AbstractObjective:To compare the types and costs of drugs prescribed by resident and staff physicians treating patients with uncomplicated essential hypertension. Design:Cross-sectional study, using a computer-based medical record database. Setting:Primary care internal medicine clinic in a large teaching hospital. Patients/participants:Hypertensive patients seen by ten postgraduate year-1 (PGY-1) and PGY-2 primary care internal medicine residents and four staff physicians practicing in the same clinic. Measurements and main results:The types and costs of antihypertensive drugs prescribed for the patients treated by resident and staff physicians were compared. A larger proportion of patients of resident physicians than of staff physicians were treated with calcium channel blockers [19(15%) vs. 40(4%), p<0.001]; residents prescribed thiazide diuretics less frequently and beta-blockers more frequently than did staff physicians, although these differences were not significant. The estimated average wholesale price of antihypertensive drugs for patients cared for by residents was 35% higher than that for patients cared for by staff physicians (

The medical query language

0.73 vs.

Use of open standards to implement health maintenance guidelines in a clinical workstation

0.54, p=0.048). This difference was not fully explained by differences in practice composition. Conclusions:Resident physicians in this study selected more expensive medications to treat hypertension than did their faculty preceptors, even when differences in practice composition were considered.

Costar in a specialty clinic: the mgh transplant unit system

The Medical Query Language (MQL) is an English-like query language with which a user with little or no training in programming or computer science can formulate and satisfy inquiries on data contained in his/her Standard MUMPS database. To date, major applications of MQL have been in the areas of quality assurance, medical research, and practice administration at sites using the Computer Stored Ambulatory Record (COSTAR) database system.

Optimizing healthcare research data warehouse design through past COSTAR query analysis.

We are developing a clinical workstation which integrates access to health maintenance guidelines with access to a computer-based medical record. In order to enhance the portability of such a system, we emphasize the use of open standards which can be used in diverse clinical environments. We discuss the use of relational database and expert system technology to provide both patient-specific and patient-independent access to clinical guidelines. We use the Arden Syntax as the format for a textual library which facilitates the storage of structured medical knowledge.

COSTAR: A Comprehensive Medical Information System for Ambulatory Care

COSTAR was originally designed for use in an ambulatory care clinic. This paper describes the adaptation of COSTAR for use in the Kidney Transplant Unit of the Massachusetts General Hospital. With few changes, the system was modified to make it compatible with the needs of the Transplant Unit that include the clinical care of both impatients and outpatients as well as administration and research. COSTAR was chosen over other available file management systems because the time-orientation of the COSTAR record make it ideally suited to the tracking of time-dependent episodes in this population. The directories were modified to include the highly specialized medical vocabulary associated with renal disease and transplantation. Forms specific to rejection and complications of transplantation were developed. The flexibility of the Medical Query Language permitted the development of many features to meet special reporting needs.