Warner V. Slack

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.

Patient reaction to computer-based medical interviewing☆

Abstract Patients, when interfaced in conversation with a computer programmed as a model of the physician interviewer, have been found to react positively to the experience.

Collection of a clean voided urine specimen: a comparison among spoken, written, and computer-based instructions.

In an effort to compare different methods of instructing patients, 99 women 18-25 years of age were given computer, spoken, weitten, or no instructions for the collection of a clean voided urine specimen. The group who received computer instructions was the most uniform in its performance (P less than 0.002, F-test) and reported the fewest procedural problems (P less than 0.02, Fisher test). In addition, this group had fewer contaminating bacteria than the group who received written instructions (P less than 0.03 , Mann-Whitney test). The group who received no instructions had more bacteria (P less than 0.0001, Mann-Whitney test) than any of the other groups. The effectiveness of the computer instruction was probably related to numerous attributes, including the individualized quality of the dialogue, self-pacing, self-testing, and privacy.

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.

Computer-based interviewing system dealing with nonverbal behavior as well as keyboard responses.

A digital computer has been programmed to conduct a medical interview while simultaneously monitoring the heart rate and keyboard response latency of the respondent for each question frame. The program can branch to new frames contingent upon the heart rate and response latency values, as well as the keyboard responses, and thus alter the course of the interview on the basis of this nonverbal information. The program is presented as a technique for studying the use of nonverbal respondent behavior in automated, clinical interviews.

Reflections on electronic medical records: When doctors will use them and when they will not

PURPOSE Our purpose is to counter the common wisdom that doctors are refractory to change and therefore responsible for the limited use of electronic medical records. METHODS We draw on experience with electronic medical records in two Harvard Medical School teaching hospitals dating back to the early 1980s. RESULTS Doctors quickly become ardent users of electronic medical records if the software is sufficiently helpful in the care of their patients. CONCLUSIONS The key to enthusiastic acceptance of electronic medical records is computing that is easy to use and helpful to doctors, nurses, and other clinicians in the care of their patients.

The CCC system in two teaching hospitals: a progress report

Computing systems developed by the Center for Clinical Computing (CCC) have been in operation in Beth Israel and Brigham and Womens hospitals for over 10 years. Designed to be of direct benefit to doctors, nurses, and other clinicians in the care of their patients, the CCC systems give the results of diagnostic studies immediately upon request; offer access to the medical literature: give advice, consultation, alerts, and reminders; assist in the day-to-day practice to medicine, and participate directly in the education of medical students and house officers. The CCC systems are extensively used, even by physicians who are under no obligation to use them. Studies have shown that the systems are well received and that they help clinicians improve the quality of patient care. In addition, the CCC systems have had a beneficial impact on the finances of the two hospitals, and they have cost less than what many hospitals spend for financial computing alone.

Computer-Based Patient Interviewing

The medical history, which may well be the physicians most important diagnostic tool, has long been neglected. The computer is well suited to efficient patient interviewing. This two part article describes a computer-based technic for taking general medical and specialty histories directly from patients.

A History of Computerized Medical Interviews

My work with patient/computer dialogue began in 1964 in collaboration with Philip Hicks, Lawrence Van Cura, and other colleagues at the University of Wisconsin. We hypothesized that we could program a computer to take a medical history directly from a patient. Our motivation came in part from a theoretical question: Could a computer model the physician? Could it actually interview a patient? There were also practical motives. Northern Wisconsin was short of physicians; for those who were seeing up to 40 or 50 patients a day, there was barely enough time to ask “Where does it hurt?,” let alone all the other questions in the standard interview. In America, taking medical histories is a time-consuming and expensive process; talk is not cheap in medicine.