The design of a rule-based clinical event monitor in a multi-vendor hospital computing environment. The Clinical Event Monitor (CEM) described here is a prototype system designed to explore the issues involved in building an institutional CEM that permits rapid, automated evaluation of clinical transactions and notification to clinicians of exceptional events in a multi-vendor computing environment. The CEM uses expert systems, database, and systems integration techniques. Ancillary (departmental) applications, including as Patient Registration, Laboratories, and Pharmacy have been licensed from commercial vendors. Application-to-application and application-to-database interfaces were built to mirror subsets of the ancillary patient databases into an institutional relational database (Oracle). The CEM receives registration updates via an HL7 message and evaluates data dependencies in rules via an interface to the relational database. The CEM engine was built using Nexpert, a commercially available expert system shell. Our short term goals were to: (1) build and maintain a patient census within the expert system environment via net based HL7 update broadcasts; (2) explore the data-driven features of Nexpert, (3) deliver prototype exception reports. This paper describes in general terms the design features of the CEM and in detail the features of a patient registry to NEXPERT bridge (from Oracle via HL7 structured transactions to NEXPERT) and the delivery of exception reports.


Prevention of adverse drug events through computerized surveillance. Adverse drug events (ADEs) are a serious health problem and are the leading adverse event experienced by hospitalized patients. Numerous hospitals have used different methods to improve the reporting of ADEs but few have undertaken studies aimed at the prevention of ADEs. We found that computerized ADE surveillance identified significantly more ADEs than our previous voluntary reporting method. Moreover, the computerized ADE surveillance system created a database of ADEs which allowed us to analyze the ADEs and design methods for prevention. We found that computer alerts of previously known drug allergies generated when drugs were ordered significantly reduced the number of type B ADEs, 56 vs 8 (p < 0.001). In addition, we found that the timely surveillance of ADEs combined with physician notification reduced the number of severe ADEs, 41 vs 12 (p < 0.001). Initial analysis of the ADE database has shown that on average patients with type B ADEs are hospitalized longer (17 vs 14 days) and have larger hospitalization costs ($30,617 vs $23,256) than patients with type A ADEs. Patients with severe ADEs also are hospitalized longer (20 vs 13 days) and have larger hospitalization costs ($38,007 vs $22,474) than patients with moderate ADEs. This indicates that the prevention and early treatment of ADEs can reduce the length of hospitalization and result in a considerable cost savings to the hospital.


Formalized decision-support for cardiovascular intensive care. The massive volume of hemodynamic data routinely available within the Cardiovascular Intensive Care Unit (CVICU) can adversely affect the quality, relevance and timing of hemodynamic management decisions on patients after cardiac surgery. Yet, at the same time, the lack of appropriate treatment-outcome data and access to prior CV case histories deprives the clinician of any opportunity to improve personal decision-making skill and assess the effectiveness of various treatment methods. This paper presents a formalized decision-support model for CVICU that incorporates expert and quantitative knowledge, as well as prior outcome and case experience to augment the clinician's decision-making capability. This includes the proposed use of optimal hemodynamic patterns derived from outcome analysis as therapy goals, expert rules and trend analysis to interpret incoming data, standardized protocols based on predefined hemodynamic patterns from clinical cases, and access to the database for similar case comparison. Most importantly, the model suggests an integrated approach where the clinical database is not only a documentation source for the patient, but can also serve as an outcome research database where clinical experience can be formalized and combined with expert knowledge to influence future therapy decisions. At present, a prototype is being developed at the CVICU of the University of Alberta Hospitals on a Unix platform using ART-IM, C and Ingres. Once implemented, the prototype will be evaluated on a small group of CV patients for its effectiveness and acceptability to clinicians.


Probability estimation for biomedical classification problems. Suppose that we wish to know the probability that an object belongs to a class. For example, we may wish to estimate the probability that a patient has a particular disease, given a set of symptoms, or we may wish to know the probability that a novel peptide binds to a receptor, given the peptide's amino-acid composition. The conventional approach is to first use a classification algorithm to find partitions in feature space and to assign each partition to a class, and then to estimate the conditional probabilities as the proportion of patients or peptides that are correctly and incorrectly classified in each partition. Unfortunately, this estimation method often gives probability estimates that are in error by 20% or more, and thus can cause incorrect decisions. We have implemented and compared alternative methods. In Monte Carlo simulations the alternative methods are substantially more accurate than is the current method.


Combining logistic regression and neural networks to create predictive models. Neural networks are being used widely in medicine and other areas to create predictive models from data. The statistical method that most closely parallels neural networks is logistic regression. This paper outlines some ways in which neural networks and logistic regression are similar, shows how a small modification of logistic regression can be used in the training of neural network models, and illustrates the use of this modification for variable selection and predictive model building with neural networks.


An application of least squares fit mapping to clinical classification. This paper describes a unique approach, "Least Square Fit Mapping," to clinical data classification. We use large collections of human-assigned text-to-category matches as training sets to compute the correlations between physicians' terms and canonical concepts. A Linear Least Squares Fit (LLSF) technique is employed to obtain a mapping function which optimally fits the known matches given in a training set and probabilistically captures the unknown matches for arbitrary texts. We tested our method with 16,032 texts from the Mayo Clinic, and judged the results using human-assigned answers. In a test for comparison, the LLSF mapping achieved a precision rate of 89% at 100% recall, outperforming alternative approaches including string matching (36% precision), string matching enhanced by morphological parsing (51% precision), and statistical weighting (61% precision).


Comparison of different information content models by using two strategies: development of the best information algorithm for Iliad. Iliad is a diagnostic expert system for internal medicine. Iliad's "best information" mode is used to determine the most cost-effective findings to pursue next at any stage of a work-up. The "best information" algorithm combines an information content calculation together with a cost factor. The calculations then provide a rank-ordering of the alternative patient findings according to cost-effectiveness. The authors evaluated five information content models under two different strategies. The first, the single-frame strategy, considers findings only within the context of each individual disease frame. The second, the across-frame strategy, considers the information that a single finding could provide across several diseases. The study found that (1) a version of Shannon's information model performed the best under both strategies---this finding confirms the result of a previous independent study, (2) the across-frame strategy was preferred over the single-frame strategy.


Reuse of knowledge represented in the Arden syntax. Knowledge Data Systems is building a medical expert system for monitoring clinical events. This system uses the Arden syntax as a knowledge representation. Having encoded may different types of rules in the Arden syntax, we have noticed a number of shortcomings of the syntax. Many of these shortcomings originate from Arden's procedural orientation, from its failure to separate factual medical knowledge from knowledge of how the medical facts should be applied to a particular clinical situation. The absence of this separation leads to redundancy of knowledge and to difficulties in knowledge reuse. We suggest that standards for representing medical logic preserve this separation to engender knowledge reuse. We propose a general framework for representing medical logic which supports both knowledge sharing and reuse.


The MEDLINE Retriever.

The MEDLINE Retriever. Baylor College of Medicine has developed the MEDLINE Retriever, a tool to query MEDLINE, the data-base of medical literature at the National Library of Medicine. The MEDLINE Retriever communicates via the Internet to achieve excellent response time for MEDLINE queries. It uses the X Window System and the Motif toolkit, and employs the Knowbot Operating Environment developed by the Corporation for National Research Initiatives. We discuss the architecture of the MEDLINE Retriever, focusing on the graphical user interface that we have developed, as well as our experiences in developing and deploying the MEDLINE Retriever at Baylor. The MEDLINE Retriever is an extension of Baylor's IAIMS design concept that brought forth the Virtual Notebook System, and fits well with Baylor's aims with regard to the High Performance Computing Initiative.


Performance appraisal of online MEDLINE access routes. To compare the performance and cost of 11 online MEDLINE systems with MEDLINE at Elhill. Comparative study. SYSTEMS: Eleven online daytime systems commercially available in North America offering the MEDLINE database. Number of relevant citations, number of irrelevant citations, proportion of searches producing no relevant citations and cost per relevant citation were analyzed for each system. Relevance and cost for each system were compared with direct searching of MEDLINE through NLM for librarian and clinician search strategies for 18 clinical questions. The citations retrieved by both strategies were pooled and rated for relevance on a 7-point scale. Numbers of relevant and irrelevant citations and cost per relevant citation were higher for clinician searches than librarian searches, reflecting the higher total number of citations retrieved by the clinician approaches. A lower proportion of clinician searches produced no relevant citations than librarian searches. Eleven daytime MEDLINE systems performed similarly in terms of retrieval and cost within similar searching groups. Clinicians, however, tended to capture larger overall retrievals resulting in higher numbers of relevant and irrelevant citations than librarians.


Grateful Med on an institutional local area network. Grateful Med version 6.0 provides new features very desirable to network users. These include: a single copy of the application resident on a server providing access to many users; a new communications architecture which provides access to Medline via the Internet or local network modems; additional scripting capabilities allowing local customization. These new features reduce the overhead in installing and maintaining Grateful Med (GM), allow much quicker downloading of citations and abstracts from Medline, and remove the requirement of a local modem for each PC accessing Medline.


Developing a clinical hypermedia corpus: experiences from the use of a practice-centered method. This paper outlines a practice-centered method for creation of a hypermedia corpus. It also describes experiences with creating such a corpus of information to support interprofessional work at a Primary Healthcare Center. From these experiences, a number of basic issues regarding information systems development within medical informatics will be discussed.


Q & A: a query formulation assistant.

Q & A: a query formulation assistant. Inexperienced users of online medical databases often do not know how to formulate their queries for effective searches. Previous attempts to help them have provided some standard procedures for query formulation, but depend on the user to enter the concepts of a query properly so that the correct search strategy will be formed. Intelligent assistance specific to a particular query often is not given. Several systems do refine the initial strategy based on relevance feedback, but usually do not make an effort to determine how well-formed a query is before actually performing the search. As part of the Interactive Query Workstation (IQW), we have developed an expert system, Questions and Answers (Q&A), that assists in formulating an initial strategy given concepts entered by the user and that determines if the strategy is well-formed, refining it when necessary.


Using ethnography to build a working system: rethinking basic design assumptions. The problem of user acceptance of knowledge-based systems is a current concern in medical informatics. User acceptance should increase when system-builders understand both the needs of potential users and the context in which a system will be used. Ethnography is one source of such understanding. This paper describes the contribution of ethnography (and an anthropological perspective) during the first year of a three-year interdisciplinary project to build a patient education system on migraine. Systematic fieldwork is producing extensive data on the information needs of migraineurs. These data call into question some of the assumptions on which the project was based. While it is not easy to rethink our assumptions and their implications for design, using ethnography has enabled us to undertake this process relatively early in the project at a time when redesign costs are low. This should greatly improve our chances of building a system that meets the needs of real users, thus avoiding the troublesome problem of user acceptance.


Involving patients in health care: explanation in the clinical setting. The long-term goal of our research is to improve the overall effectiveness of physicians' time, by improving the information exchange between physicians and chronic-care patients, initially migraine patients. The computer system we are constructing has a partial knowledge base about migraines, common therapies, and common side effects of those therapies. The system consists of two main programs: data collection and explanation. The design of our system is based on empirical data concerning patients' information needs.


Concept graphics: a language for medical knowledge. This paper makes a case for Concept Graphics, a novel form of medical knowledge representation. Concept Graphics are assemblies of icons each of which has a precise meaning. Individual icons are metaphors of the object or process they represent. Concept Graphics are analogs of pathological situations, their symptoms, signs and other relevant components necessary for a diagnosis. We propose three principal areas of application for Concept Graphics: medical education, medical records management and research based on medical records. Our earlier work in medical education showed a clear advantage in using Concept Graphics in parallel with text of equivalent information content, over text alone. A Concept Graphics based intelligent tutoring systems (ITS) is being developed. In the area of medical records management we are developing a system for the rapid identification of relevant records based on rapid visual screening. The Concept Graphics based system can reveal properties common to specific groups of records. As such the graphics are a research tool.


An object oriented approach to interpret medical knowledge based on the Arden syntax. A method is presented where medical knowledge modules, written in the Arden Syntax, are used in a decision-support system (DSS). Knowledge modules are, after syntax-checking, translated into the object oriented programming language C++, compiled and linked to the DSS. The object oriented approach together with developed tools, such as knowledge editor and translator, makes it possible to implement the Arden Syntax and to get an efficient, easy-maintained DSS. Work on a prototype shows that this approach has several advantages when building a DSS where medical knowledge is represented in the Arden Syntax.


An interactive graphics information system for familial data. GRIFFIN, an interactive graphics system for studying familial information, facilitates viewing of complex databases and introduces graphical representations of multivariate scalar data into a conventional pedigree display format.


Medical informatics and institutional strategy. Programs in medical informatics can help academic medical centers make effective use of information technology. But to achieve the greatest strategic benefits from these programs, an institution must forge proper linkage between informatics and its overall effort to deploy computing in research, education and patient care. Here we explore this linkage and the ways in which it can be established and managed.


Work-sampling: a statistical approach to evaluation of the effect of computers on work patterns in the healthcare industry. An increasing number of healthcare institutions are in the process of implementing clinical computing systems. The need for an accurate assessment of the clinical, administrative, social, and financial effects of such systems has been recognized. Techniques have been developed to evaluate these effects on the work patterns of healthcare workers including: 1) time-motion analysis, 2) subjective evaluations, 3) review of departmental statistics, 4) personal activity records, and 5) work-sampling. This manuscript reviews these techniques, discusses both positive and negative aspects, and presents a step-by-step description of work-sampling.


Informatics Workup.

Informatics Workup. We introduce the concept of a Medical Informatics Workup performed by fourth year medical students working in a busy inner-city Emergency Room. These students use portable computers (Macintosh PowerBook 170s connected to a removable cartridge hard drive and CD-ROM drive) to do the patient workups. The PowerBook 170 contains the automated medical record entry software (IMR-E), five expert system software packages, and a program that allows the PowerBook to emulate a PC-compatible computer. With this configuration the student has a portable system that allows for the creation of a computerized medical record at the patient's bedside, along with the ability to analyze the data and generate a list of differential diagnoses.


PC GI board review. A ToolBook application for postgraduate review of Gastroenterology. "Hypertext" applications have become an important educational resource for medical teaching. ToolBook version 1.5 allows the import of SVGA 256 color, 640 x 480 pixel images. We developed a program for the review of Gastroenterology by Subspecialty Board applicants which included digitized pathology, endoscopy, dermatology, and radiology images interfaced with textual description. 5 cases were presented with 6 questions per case to test the user's comprehension of the material. A scoring function was included to give feedback to the users. An evaluation questionnaire was also completed to survey user satisfaction with the program. A similar "shell" could be applied to other teaching programs.


Digital patient records and the medical desktop: an integrated physician workstation for medical informatics training. The Institute of Medicine and others have advocated a shift from a paper-based to an electronic medical record and many authorities have advanced the concept of a physician workstation that can provide access to a wide variety of both clinically and reference oriented medical information. We have developed a working model of an integrated physician workstation based on a graphically oriented "Medical Desktop," for personal computers. This system gives the user access to much of the information necessary for the practice of medicine, by integrating an electronic medical record (notes, orders, consults, lab values, and radiological studies, organized both independently and in a "Visual Chart") with tools such as drug references, clinical manuals, textbooks of medicine, literature searching, expert system decision support, and electronic communication. It contains an on-line help system that facilitates use and allows access to all the systems' capabilities. This system has been used to teach students and physicians the methods and potential of computer-based medical information management to prepare them for the impact of computers in their practices and educate them concerning the imperative for the involvement of all health care providers in implementing these changes.


Increases in knowledge and use of information technology by entering medical students at McMaster University in successive annual surveys. To determine self-reported microcomputer and information technology competency, access, and usage by entering medical students and their perceptions of the need for training in additional applications. Cross-sectional surveys of successive classes. McMaster University Faculty of Health Sciences Medical Undergraduate Program, which has a 33-month, problem-based, self-directed learning curriculum and a high applicant-to-student ratio. Medical school classes entering in 1987, 1988, and 1989. Response rates were 80%, 90%, and 86% respectively. A self-report questionnaire was sent to each student, with up to two follow-up letters to prompt a response. There was a progressive rise in reported information technology access and use for the three years. For the classes starting in 1987, '88, and '89 respectively, computer access was 29%, 49%, and 49% (P < 0.002 for linear trend), and, among those with computer access, modem access was 17%, 29% and 50% (P = 0.012). Self-service MEDLINE use on CD-ROM at the Health Sciences Library was 65%, 75%, and 89% respectively (P < 0.001) for all respondents within the first few months of starting medical school. Over 50% of each class stated they would take courses, if available, on clinical applications software, office management, online searching, filing, and CD-ROM searching. Half of the most recent entering students already had access to a personal computer and most wished to learn computer applications that would assist them with patient management, and with information access and organization. Medical schools need to address which applications they will teach or make available and how to bring all students to acceptable competency in their use.


Anticoagulation therapy advisor: a decision-support system for heparin therapy during ECMO. We present a case study describing our development of a mathematical model to control a clinical parameter in a patient--in this case, the degree of anticoagulation during extracorporeal membrane oxygenation (ECMO) support. During ECMO therapy, an anticoagulant agent (heparin) is administered to prevent thrombosis. Under- or over-coagulation can have grave consequences. To improve control of anticoagulation, we developed a pharmacokinetic-pharmacodynamic (PK-PD) model that predicts activated clotting times (ACT) using the NONMEM program. We then integrated this model into a decision-support system, and validated it with an independent data set. The population model had a mean absolute error of prediction for ACT values of 33.5 seconds, with a mean bias in estimation of -14.3 seconds. Individualization of model-parameter estimates using nonlinear regression improved the absolute error prediction to 25.5 seconds, and lowered the mean bias to -3.1 seconds. The PK-PD model is coupled with software for heuristic interpretation of model results to provide a complete environment for the management of anticoagulation.


Drug delivery optimization through Bayesian networks. This paper describes how Bayesian Networks can be used in combination with compartmental models to plan Recombinant Human Erythropoietin (r-HuEPO) delivery in the treatment of anemia of chronic uremic patients. Past measurements of hematocrit or hemoglobin concentration in a patient during the therapy can be exploited to adjust the parameters of a compartmental model of the erythropoiesis. This adaptive process allows more accurate patient-specific predictions, and hence a more rational dosage planning. We describe a drug delivery optimization protocol, based on our approach. Some results obtained on real data are presented.


An evaluation of explanations of probabilistic inference. Providing explanations of the conclusions of decision-support systems can be viewed as presenting inference results in a manner that enhances the user's insight into how these results were obtained. The ability to explain inferences has been demonstrated to be an important factor in making medical decision-support systems acceptable for clinical use. Although many researchers in artificial intelligence have explored the automatic generation of explanations for decision-support systems based on symbolic reasoning, research in automated explanation of probabilistic results has been limited. We present the results of an an evaluation study of INSITE, a program that explains the reasoning of decision-support systems based on Bayesian belief networks. In the domain of anesthesia, we compared subjects who had access to a belief network with explanations of the inference results, to control subjects who used the same belief network without explanations. We show that, compared to control subjects, the explanation subjects demonstrated greater diagnostic accuracy, were more confident about their conclusions, were more critical of the belief network, and found the presentation of the inference results more clear.


ECG data compression by modeling.

ECG data compression by modeling. This paper presents a novel algorithm for data compression of single lead Electrocardiogram (ECG) data. The method is based on Parametric modeling of the Discrete Cosine Transformed ECG signal. Improved high frequency reconstruction is achieved by separately modeling the low and the high frequency regions of the transformed signal. Differential Pulse Code Modulation is applied on the model parameters to obtain a further increase in the compression. Compression ratios up to 1:40 were achieved without significant distortion.


A needs analysis for computer-based telephone triage in a community AIDS clinic. This study describes the complexity of the telephone-triage task in a community-based AIDS clinic. We identify deficiencies related to the data management for and documentation of the telephone-triage encounter, including inaccessibility of the medical record and failure to document required data elements. Our needs analysis suggests five design criteria for a computer-based system that assists nurses with the telephone-triage task: (1) online accessibility of the medical record, (2) ability to move among modules of the medical record and the triage-encounter module, (3) ease of data entry, (4) compliance with standards for documentation, and (5) notification of the primary-care physician in an appropriate and timely manner.


Object-oriented Information System in the HELIOS Medical Software Engineering Environment. This paper presents the architecture of the Information System of HELIOS, a medical Software Engineering Environment. It is an object oriented framework for the development of medical applications which puts particular emphasis on tools and techniques favouring reuse of previous work and enhancing collaboration between developers.


The development of a virtual database to provide on-line access to a large archive of clinical data. The archival database of the HELP Hospital Information System at LDS Hospital is too large to be stored on line. The archival data are important for clinical and research applications. Demountable disk packs have been used to store the archival database. This method of storage has four significant disadvantages. A virtual database was developed to overcome the limitations of this data-management scheme. This virtual database enables the transparent use of appropriate low-cost network-based storage technology to provide on-line availability of the entire archive of clinical data. The virtual database successfully resolves the problems associated with disk packs, and opens the door to enhanced use of the data for clinical and research applications.


The organization engine: virtual data integration. The Organization Engine is an early example of Virtual Data Integration--providing the appearance of integration at the desktop without modifying existing infrastructure. Starting with the Organization Engine, eight programming days were needed to provide uniform desktop access to a CODASYL-compliant hospital information system and to a MUMPS-based radiology information system (the technique is equally effective for relational and other data bases). The resulting tool provides a seamless integration of these two systems, image storage, pre-recorded audio, and document storage. In addition to providing uniform access, the tool allows healthcare providers to organize the data to suit their individual needs. The ease of this integration lies in two simple techniques: the transformation of data from all sources into a single, homogeneous representation, and the use of simple customization files to describe new object types and formats. The approach is sufficiently general to allow the integration of applications which present external interfaces of radically different forms. Two such forms are discussed here: data map publication and transactions.


Computer-focused modification of physician prescribing behavior. Prescribing data downloaded from the MUMPS-based hospital information system of the Department of Veterans Affairs has been used to target specific interventions aimed at changing physician prescribing patterns. Focused interventions aimed at specific groups of physicians, patients, clinics, and drugs have proven effective in reducing pharmaceutical costs by rationalizing prescribing patterns. The results indicate the potential usefulness of a microcomputer with a commercial database program in manipulating hospital information system data.


Evaluating drug prescribing in a large, ambulatory population: application of an embedded expert system. DUR is a process of problem detection and intervention designed to improve the quality and economy of drug prescribing. Retrospective DUR attempts to detect and address patterns of prescribing that might be indicative of inappropriate therapy. When the process is extended to a largely ambulatory population such as Medicaid beneficiaries, a number of complications are introduced due to the large numbers of patients and sparsity of data. In order to examine the impact of implementing a Medicaid DUR program, we developed a system that would apply screening criteria to prescription claims. It has been used to screen prescribing of groups of two antihypertensive drugs in the 1990 Maryland Medicaid population for 177,409 Medicaid eligible individuals. Potentially significant problems were detected with respect to dosing, duplication of therapeutic agents and drug interactions. The system represents, we believe, a significant improvement in the ability to detect and report prescribing decisions by increasing the specificity of the detection system. By the application of this system to a set of real-world data, we have demonstrated that it is feasible to implement such a system and derive results that are potentially useful in reducing the incidence of inappropriate physician decision-making.


A critical appraisal of the literature on the effects of computer-based clinical decision support systems on clinician performance and patient outcomes. To review the evaluations of computer-based clinical decision support systems (CDSS's). The literature collected in the MEDLARS, EMBASE, SCISEARCH and INSPEC databases was searched from 1974 to the present. The reference lists of relevant articles were reviewed as were conference proceedings. Prospective, controlled studies were included. Studies were rated for methodological quality. Study quality was assessed and data on study setting, subjects, method of allocation, and computer system were collected and verified using a structured form. There is considerable heterogeneity in both systems evaluated and design features of those systems. Future evaluations of CDSS's should focus on methodological issues in order to enhance overall quality of evaluations.


Continuous quality improvement and medical informatics: the convergent synergy. Continuous quality improvement (CQI) and medical informatics specialists need to converge their efforts to create synergy for improving health care. Health care CQI needs medical informatics' expertise and technology to build the information systems needed to manage health care organizations according to quality improvement principles. Medical informatics needs CQI's philosophy and methods to build health care information systems that can evolve to meet the changing needs of clinicians and other stakeholders. This paper explores the philosophical basis for convergence of CQI and medical informatics efforts, and then examines a clinical computer workstation development project that is applying a combined approach.


An evaluation of concept based latent semantic indexing for clinical information retrieval. Latent Semantic Indexing (LSI) of surgical case report text using ICD-9-CM procedure codes and index terms was evaluated. The precision-recall performance of this two-step matrix retrieval process was compared with the SMART Document retrieval system, surface word matching, and humanly assigned procedure codes. Human coding performed best, two-step LSI did less well than surface matching or SMART. This evaluation suggests that concept-based LSI may be compromised by its two-stage nature and its dependence upon a robust term database linked to main concepts. However, the potential elegance of partial- credit concept matching merits the continued evaluation of LSI for clinical case retrieval.


Coordinated delivery of clinical care: the "re-integration" of the medical group practice. This paper suggests that for medical knowledge to be effective, it must be reliably translated into a series of synchronized activities, both clinical and operational. The goal of medical information science must be not only to identify the best course of care, but also through the use of systems for the ordering, scheduling, and deployment of staff and resources to assure that the planned course of care is reliably and efficiently delivered in actual practice settings. We present a brief history of several innovations in patient care coordination and logistics at Mayo Clinic to provide background for the main concepts presented. The principle of patient care coordination underlying this history of innovation is shown to have evolved into a new need for information systems capable of proactively effecting the delivery of care through patient, staff and resource deployment and monitoring.


Words, concepts, or both: optimal indexing units for automated information retrieval. What is the best way to represent the content of documents in an information retrieval system? This study compares the retrieval effectiveness of five different methods for automated (machine-assigned) indexing using three test collections. The consistently best methods are those that use indexing based on the words that occur in the available text of each document. Methods used to map text into concepts from a controlled vocabulary showed no advantage over the word-based methods. This study also looked at an approach to relevance feedback which showed benefit for both word-based and concept-based methods.


The semantic structure of the UMLS Metathesaurus. Meta-1.1, the UMLS metathesaurus, represents medical knowledge in the forms of names of concepts and links between those concepts. The representations of the semantic neighborhood of a concept can be thought of as dimensions of the property of semantic locality and include term information (broader, narrower, or otherwise related), the contextual information (parent-child, siblings in a hierarchy), the semantic types, and the co-occurrence data (links discovered empirically from concepts used to index the medical literature.) The degree of redundancy of each of these dimensions was investigated by reviewing the extent of multiple presentations of concepts which appear as related to a given concept. The degree of overlap was surprisingly small. While the co-occurrence data finds some of the links represented by other dimensions, those links are but minute fractions of the vast amount of co-occurrence derived links. Because parent-child relationships are often subsumptive (or categorical) in nature, it might be expected that siblings usually share the same semantic types. While true in the aggregate, the wide variance in percent of types shared may reflect the intended usages of the source vocabularies. Noun phrases were extracted from the definitions of 40 concepts in Meta-1 in order to assess systematically the coverage of important concepts by Meta-1, and to assess whether the links between these definitional concepts, which may have special value, and the concept being defined were indeed present. Out of 161 of these definitional concepts, 29 were not represented in Meta-1, and 37 of those represented in Meta-1 had no direct link to the concept they were defining.(ABSTRACT TRUNCATED AT 250 WORDS)


How well does ICD9 represent phrases used in the medical record problem list? We are considering using the International Classification of Diseases with Clinical Modifications, Ninth Revision (ICD9) as the basis for an automated problem list for a clinical information system. To determine physician satisfaction with an ICD9 representation of phrases used in the medical record problem list, we asked 6 physicians to evaluate ICD9 representations of 332 phrases taken from medical record problem lists, using a scale of 1(extremely dissatisfied) to 5 (extremely satisfied). The mean score was 3.0; intraclass correlation for 25 phrases given to all 6 evaluators was 0.47. In 45% of the phrases the physicians were dissatisfied with the ICD9 representation. In developing an automated problem list it is desirable to improve the level of satisfaction of clinician users above this level. This could be done by modifying ICD9, using a different vocabulary to represent the problem list, or improving the method of assigning ICD9 codes.


Collaboration between unlikely disciplines in the creation of a conceptual framework for nurse-computer interactions. A unique conceptual framework for the study of nurse-computer interaction was created through the collaboration of two researchers in seemingly diverse fields: nursing informatics and developmental psychology. The framework depicts nurses and computers interacting in a system of mutual influences, exchanging information during a particular task, and proceeding on a developmental trajectory. The conceptual framework can help guide research within nursing informatics and help build a cohesive body of knowledge for the future.


Use of a neural network as a predictive instrument for length of stay in the intensive care unit following cardiac surgery. A patient's intensive care unit (ICU) length of stay following cardiac surgery is an important issue in Canada, where cardiovascular intensive care resources are limited and waiting lists for cardiac surgery exist. A predictive instrument for ICU length of stay could lead to improved utilization of existing ICU and operating room resources through better scheduling of patients and staff. We trained a neural network with a database of 713 patients and 15 input variables to predict patients who would have a prolonged ICU length of stay, which we defined as a stay greater than 2 days. In an independent test set of 696 patients, the network was able to stratify patients into three risk groups for prolonged stay (low, intermediate, and high), corresponding to frequencies of prolonged stay of 16.3%, 35.3%, and 60.8% respectively. The performance of the network was also evaluated by calculating the area under the Receiver Operating Characteristic (ROC) curve in the training set, 0.7094 (SE 0.0224), and in the test set, 0.6960 (SE 0.0227). We believe the trained network would be a useful predictive instrument for optimizing the scheduling of cardiac surgery patients in times of limited ICU resources. Neural networks are a new alternative method for developing predictive instruments that offer both advantages and disadvantages when compared to other more widely used statistical techniques.


Automated acuity scoring within a computer based medical record. This paper describes the initial development of a completely automated acuity scoring system that resides within the TMR bedside computing system at the Duke University Medical Center, Surgical Intensive Unit. The scoring system is based upon the APACHE II acuity scoring system and provides for the recalculation of acuity scoring at 12 hour intervals through the patient's ICU course. When comparing hand calculated versus computer generated acuity scores for 19 patients, discrepancies fell into three broad categories: 1) data available to the application differed from that available to the human scorer. 2) apparent transcription errors 3) data items lost or absent from the paper record. It remains to be determined if computer generated acuity scoring provides for a more accurate representation of the patient's acuity.


Optimizing staff scheduling by Monte-Carlo simulation. DOCS is a computer program which generates the staff schedule. An accounting framework is combined with an optimization technique that searches for a schedule in which all accounts are simultaneously in balance. The search is accomplished using a Monte-Carlo process which shuffles staff within the schedule. The shuffling is biased according to each staffer's account balance: the staffer who owes the most is most likely to be scheduled.


A diagnostic system that learns from experience. LiverSoar is a flexible knowledge-based system that can learn from its problem-solving experience in individual cases. Within an opportunistic abductive framework, it can diagnose liver diseases from findings in liver tissue biopsies. As more cases are encountered and more recognition knowledge is acquired, the system becomes prepared for most of the usual cases, hence solves them with less problem-solving effort. At the same time, it stays flexible enough to fall back to deliberative problem solving in more unusual cases if the acquired knowledge does not apply.


Towards unambiguous representation of patient data. In the early eighties, the goal set for the development of computer-based patient records was the creation of patient records that were analogous to the paper record. In the Netherlands, where the number of physicians using computer-based patient records is steadily increasing, this strategy has been proven successful. Although these "paper-like" computer-based patient records were suitable for patient care, they were much less suited for other purposes. Experiments showed that the use of data for other purposes than those for which they were recorded, can only be performed reliably when these data permit unambiguous interpretation. Due to a physician's limited time there is a constant tension between benefit and effort. Therefore, we should not expect the physician to provide the large amount of additional information, required for unambiguous interpretation of his record. Many of the inferences made by physicians are based on general knowledge and do not require specific, patient related information. We have focused our research on the potential of using knowledge about concepts in the patient record, to infer information, that is implicit in the patient data. The paper discusses considerations with respect to possible strategies to elicit a maximum of information with a minimum of effort from the physician.


An approach to evaluating heuristics in abduction: a case study using RedSoar--an abductive system for red blood cell antibody identification. Abduction, or inference to a best explanation, is a ubiquitous type of inference that is frequently used by humans in a wide range of tasks. However, many realistic domains have properties that make abduction computationally intractable (i.e., where the time to reach a solution increases exponentially with the number of possible explanations). We present a domain task analysis and performance evaluation of RedSoar, a plausible cognitive computational model of abduction, that accomplishes the antibody identification task in immunohematology. The task analysis reveals how a computationally intractable abductive problem, where one is seeking optimal solutions, can be reformulated to be a computationally tractable abductive problem, by seeking satisfactory rather then optimal solutions. From the satisfactory perspective, our evaluation framework of RedSoar's performance explores the computational benefits and costs of having directly available abstract hypothesis formation knowledge, and how a strong causal constraint between hypotheses and data reduces the combinatorial explosion of constructing a best explanation.


DentLE. The dental learning environment: a prototype. The State University of New York at Buffalo School of Dental Medicine was awarded a 'Model Curriculum' grant through the USPHS Bureau of Health Professions Education. The award was provided in support of the School's ongoing effort to design a 'model electronic curriculum' for the health professions. The project's development is described from its grounding in critical thinking and problem solving to a discussion of its features including the organization of its knowledge base, the layout of its computer-based oral health record, and its navigation features.


Real problems: a layered approach to constructing a patient simulation. We propose and have implemented a program, called "Real Problems", for the authoring of simulated patient encounters. This program uses a layered database approach to separate the unchanging sections of the program from the more patient-specific sections, so as to increase the speed of authoring. The user's interest is maintained through the use of graphics, sound and extensive feedback.


ATLAS-plus: multimedia instruction in embryology, gross anatomy, and histology. ATLAS-plus [Advanced Tools for Learning Anatomical Structure] is a multimedia program used to assist in the teaching of anatomy at the University of Michigan Medical School. ATLAS-plus contains three courses: Histology, Embryology, and Gross Anatomy. In addition to the three courses, a glossary containing terms from the three courses is available. All three courses and the glossary are accessible in the ATLAS-plus environment. The ATLAS-plus environment provides a consistent set of tools and options so that the user can navigate easily and intelligently in and between the various courses and modules in the ATLAS-plus world. The program is a collaboration between anatomy and cell biology faculty, medical students, graphic artists, systems analysts, and instructional designers.


T-HELPER: automated support for community-based clinical research. There are increasing expectations that community-based physicians who care for people with HIV infection will offer their patients opportunities to enroll in clinical trials. The information-management requirements of clinical investigation, however, make it unrealistic for most providers who do not practice in academic centers to participate in clinical research. Our T-HELPER computer system offers community-based physicians the possibility of enrolling patients in clinical trials as a component of primary care. T-HELPER facilitates data management for patients with HIV disease, and can offer patient-specific and situation-specific advice concerning new protocols for which patients may be eligible and the treatment required by those protocols in which patients currently are enrolled. We are installing T-HELPER at three county-operated AIDS clinics in the San Francisco Bay Area, and plan a comprehensive evaluation of the system and its influence on clinical research.


A protocol system to satisfy research specific, disease specific, physician specific, and patient specific informational needs. The Department of Medicine at Loyola University Medical Center Chicago (LUMC) has developed and is utilizing a Patient Information Protocol System (PIPS) to address clinical and research informational needs. PIPS, an integrated module of the department's Patient Information Management System (PIMS), enables end-users to access pre-defined informational templates or "protocols". Protocols detail pre-defined data requirements for patient management or clinical research needs. Each protocol consists of a defined collection of protocol elements. Protocol elements belong to an object group which has several defined attributes (e.g. description, acceptable ranges or inputs, units, and grouping keywords). Approximately 3,500 protocol elements have been identified to define treatments/drugs, symptoms/toxicity, clinical labs, x-rays/scans, physical findings, and lesion groups. Utilizing protocols, PIPS permits end-users to selectively review or capture clinical information. Patients may have several active protocols. PIPS interacts with a specialized database gateway to permit automatic capture of clinical laboratories information, and with reporting systems to produce one of several "chart-ready", time-oriented protocol summary reports. Data extraction programs operate in conjunction with PIPS to facilitate exporting of data for statistical analysis. PIPS has been in operation for over 24 months and has 63 defined protocols (40 clinical research and 23 patient care).


A clinical and research database management system for a geriatric nursing outreach program to rural elderly: purpose and general structure. The need to systematically and comprehensively manage data to support nursing services asserts itself in all areas and contexts where nursing services are delivered to patients and families. While most applications have targeted inpatient nursing services, several systems to sustain ambulatory nursing care have been proposed as well. In this paper, we outline the purpose and general structure of a custom-designed computerized database management system to support the clinical, administrative, and research operations of a geriatric nursing outreach program in rural Virginia.


The TEAM evaluation approach to Project FAMUS, a pan-Canadian risk register for primary care. The application of the TEAM--Total Evaluation and Acceptance Methodology--to the development of Project FAMUS--Family Medicine, University of Sherbrooke--is described. Project FAMUS is concerned with the establishment of a pan-Canadian risk register, the data being provided from a network of 800 family physicians distributed across Canada. Emphasis is on the first phase of the project and the overall evaluation strategy.


Health Care Plan's Nurse Advice System.

Health Care Plan's Nurse Advice System. Staff model HMO's expend great effort in handling member phone calls. Health Care Plan, Inc. has developed a computer program to aid phone room nurses in their documentation and decision making processes. The Nurse Advice system has been successfully implemented in six of eight medical centers. By providing real-time access to patient clinical data, the quality of care and service is improved.


Computerized patient information under the Privacy Act: a regulatory effectiveness analysis. Regulatory Effectiveness Analysis is a new technique for measuring compliance with a technological regulatory system. By examining the public policies, legal structures and technical tools involved in the regulatory system, it is possible to discover discontinuities which may result in non compliance with the regulatory system. This technique can be used to analyze the Veterans Health Administration's (VHA) actions under the Privacy Act.


FDA regulation of biomedical software.

FDA regulation of biomedical software. A major problem faced by biomedical software developers and users is the complexity of the regulatory regimes confronting them. Of particular concern is whether, and to what extent, they are regulated by the Food and Drug Administration (FDA) and the consequences of such regulation. Producers, distributors, and users of biomedical software often are unaware that FDA regulates many of these products as medical devices. Developers, vendors, distributors, or users of such software are subject to significant civil and criminal liability for noncompliance. This article explains the current regulatory requirements imposed on computer software developers and users by FDA, biomedical and some proactive strategies for avoiding adverse enforcement.


Decision support system and medical liability. Expert systems, which are going to be an essential tool in Medicine, are evolving in terms of sophistication of both knowledge representation and types of reasoning models used. The more efficient they are, the more often they will be used and professional liability will be involved. So after giving a short survey of configuration and working of expert systems, the authors will study the liabilities of people building and the using expert systems regarding some various dysfunctions. Of course the expert systems have to be considered only for human support and they should not possess any authority themselves, therefore the doctors must keep in mind that it is their own responsibility and as such keep their judgment and criticism. However other professionals could be involved, if they have participated in the building of expert systems. The different liabilities and the burden of proof are discussed according to some possible dysfunctions. In any case the final proof is inside the expert system by itself through re-computation of data.


A history-taking system that uses continuous speech recognition. Q-MED is an automated history-taking system that uses speaker-independent continuous speech as its main interface modality. Q-MED is designed to allow a patient to enter her basic symptoms by engaging in a dialog with the program. Error-recovery mechanisms help to eliminate findings resulting from misrecognitions or incorrect parses. An evaluation of the natural language parser that Q-MED uses to map user utterances to findings showed an overall semantic accuracy of 87 percent; Q-MED asks more specific questions to capture findings that were not volunteered, or that were unable to be parsed in their initial, open-ended form.


Augmented transition networks as a representation for knowledge-based history-taking systems. Numerous history-taking systems have been built to automate the medical history-taking process. These systems differ in their control methods, input and output modalities, and kinds of questions asked. Thus, there has emerged no standard way of representing interviewing knowledge--the expert knowledge used to govern the sequence of questions asked in an interview. This paper discusses how we use an augmented transition network (ATN) to represent the knowledge of a speech-driven automated history-taking program, Q-MED, and how, more generally, ATNs could be used as a representation for any knowledge-based history-taking system. We identify three characteristics of ATNs that facilitate the use of ATNs in interviewing systems: explicitness, hierarchical structure, and generality.


The integration of a continuous-speech-recognition system with the QMR diagnostic program. We describe a continuous-speech interface for Quick Medical Reference (QMR), which allows physicians to input spoken descriptions of physical-examination findings, or observations. We analyze the difficulties in designing a continuous-speech interface for systems that use medical terminology. We present a method for matching spoken findings names expressed in natural language to QMR terms. The method is based on a semantic representation of findings that both minimize the effect of misrecognition and derive grammars that are necessary for supporting the recognition process.


Improving the quality of emergency department documentation using the voice-activated word processor: interim results. We examined whether voice-activated word processors provide an acceptable means for emergency physicians to create medical records. Our study addressed three areas of inquiry: whether physicians can be induced to try this new technology, whether they will continue to use it after outside technical support is withdrawn, and the factors contributing to adoption and substantial use of voice-activated computers by practicing emergency physicians. This paper presents findings from the first half of the study, reflecting physicians' reported experiences while receiving onsite training followed by technical support for three months after system installation. Based on preliminary assessments, the keys to successful use appear to include physician and group commitment, acceptance of a steep learning curve, and flexibility in adapting the computer software and/or practice habits.


A curriculum database with boolean natural-language searching in HyperCard. A curriculum database including both natural-language and keyword searching was developed to assist faculty in curriculum research and reform. HyperCard (with extensions) on the Apple Macintosh provides a flexible single-user or networked environment for entering, indexing, searching and retrieving content in detailed faculty notes for the instructional activities in a four-year predoctoral curriculum.


Teaching pathology without lectures through computer-based exercises, small-group discussions and reading. The Department of Pathology at Robert Wood Johnson Medical School teaches a 205-hour, one semester course to 150 second-year students in the fall semester of the second year. The course begins with General Pathology (4 weeks) and continues with Systemic Pathology (12 weeks). In 1986, lectures were eliminated as a means of conveying the course content. Students were expected to read the textbook and to participate in obligatory small group discussions. Extensive computer based self-learning materials were provided in both MS/DOS and Macintosh formats. In 1991, these computer resources included the full text of Robbins Pathologic Basis of Disease, extensive question banks and a guide through the Slice of Life Videodisc. Over the past 6 years this modified curriculum has been enthusiastically received by the students and faculty. Student performance on internal and external examinations has been excellent. Approximately 4% of the graduating students select pathology for their post-graduate training.


Direct physician entry of injury information and automated coding via a graphical user interface. Injury data in the paper medical record are often inaccurate or lack adequate specificity to evaluate trauma patient care. To improve the quality of recorded injury data, we are testing a graphical, anatomic-based interface for quick collection of detailed injury information directly from the trauma physician. Navigation and data collection throughout the interface are facilitated by anatomic illustrations, menus, lists, and "dialog boxes". Using a "point and click" method, the user selects a specific anatomic structure (i.e., the spleen) from drawings. Detailed injury information, specific to the selected structure, is then collected from the user in an "intelligent" modal dialog box. The software uses SNOMED III nomenclature to create and store ICD, AIS, and trauma registry codes for each injury. Users can review and print abbreviated and detailed injury information for each patient. This demonstration will walk viewers through the injury collection and review process for injuries to the abdomen. We plan to evaluate the interface for accuracy, speed, user satisfaction and resources expended by comparing it with current methods of data collection and injury coding at our level I trauma facility.


Form-based clinical input from a structured vocabulary: initial application in ultrasound reporting. Ultra-STAR (Ultrasound Structured Attribute Reporting) allows a sonographer to record reports using a hierarchic standardized vocabulary. Reports are constructed interactively by using checkboxes and radio buttons in a graphical user interface to select concepts from the vocabulary. Concepts are presented in small windows that open when needed to record further detail. Preliminary reports are printed for the referring physician. Reports are later finalized by an attending radiologist and uploaded to the hospital's information system. Clinicians involved so far prefer an outline report to a natural language format.


VA's Integrated Imaging System on three platforms. The DHCP Integrated Imaging System provides users with integrated patient data including text, image and graphics data. This system has been transferred from its original two screen DOS-based MUMPS platform to an X window workstation and a Microsoft Windows-based workstation. There are differences between these various platforms that impact on software design and on software development strategy. Data structures and conventions were used to isolate hardware, operating system, imaging software, and user-interface differences between platforms in the implementation of functionality for text and image display and interaction. The use of an object-oriented approach greatly increased system portability.


PC CLIN-SIM: a toolbook based clinical simulation environment. The Departments of Computer Medicine, Health Care Sciences, Medicine, and Electrical Engineering & Computer Science at the George Washington University have joined forces to create a clinical simulation program. The purpose of this program is to provide experience in the management of complex patient populations (eg geriatrics). A number of simulation programs are available commercially, however none provide adequate geriatric content, or were deemed to lack functionality important to the developers. The immediate goal of this effort was to create a computer-based, core curriculum in geriatric medicine for medical and allied health students. The curriculum includes case simulations linked to a comprehensive reference database. The development objectives were to create an intuitive, friendly, consistent user interface which could serve as a shell for additional content areas. In order to increase fidelity, free text entry and time simulation were included.


PathPics: an image-based instructional program used in the pathology and histology curriculum and transmitted over a wide area network. PathPics is an image review and tutorial program developed at the University of California, San Diego (UCSD) School of Medicine as an adjunct to the preclinical Pathology and Histology curriculum. It incorporates faculty expertise and provides a framework for self-paced study of this visually-oriented material. The program is served over our wide area network and runs on color-capable Macintosh computers. PathPics was added to the curriculum in January, 1992, and has been enthusiastically received by the students.


Images in Rheumatology: a multimedia program for medical education. In recent years, undergraduate medical education has benefited from the use of computer-based instructional programs. However, in the case of clinical and postgraduate medical education there is a scarcity of such programs, particularly those with access to high-resolution images. Having a fundamental knowledge base of disease-associated images is crucial for the physicians during the diagnostic process. To fill this gap in clinical instruction in the rheumatic diseases, Images in Rheumatology was developed. By using a hypertext format, one may select representative color images of a clinical disease or view x-ray changes typical for one of the rheumatic disorders. In addition, for each displayed image there is an associated sound-bite which explains in detail what abnormalities are present and how the user may differentiate the disease being viewed from other illnesses. An extensive review element is also included so that one can assess their fundamental knowledge of rheumatologic images. The Images in Rheumatology program has been implemented in the DOS (IBM Microchannel). and Windows environments.


Physician use of an NICU laboratory reporting system. Clinical workstation developers may gain useful insights from studies of physician acceptance and use of computer systems that have been incorporated into daily practice. We used a physician survey, intrinsic monitors built into the system and an observational study to assess physician acceptance and use of a touchscreen workstation that was put in place in an NICU in 1985. Each of the 87 physicians assigned to the 30 bed NICU during the two academic years beginning July, 1987 was sent a questionnaire that assessed experience and attitudes about the system. The 70 responding physicians (80 percent) were unanimous in agreeing or strongly agreeing that the system was "easy to learn" (57 reported it taking less than five minutes), "easy to use", and "integrates smoothly into patient care activities". Over 94 percent of the physicians agreed or strongly agreed that the system was "fast", "saves time", and was "reliable and dependable." Sixty-three of the responding physicians (90%) reported using the system two or more times a day with 53 using it more than five times daily. The most frequently requested new feature was that of time-trend graphs (51 occurrences). The intrinsic monitors were useful in validating design decisions and survey results but also provided new insights relevant to security issues. Similarly, the observation study reinforced some of the survey results but also highlighted an additional issue not brought out by the other two assessment methods. The overall assessment indicated that the system has been both well-accepted and well-used by its intended clinical clientele.


DentLE. The Dental Learning Environment: a prototype demonstration. DentLE, the Dental Learning Environment is a hypermedia software system being prototyped as part of a research and development project at the State University of New York at Buffalo School of Dental Medicine. The design seeks to reach beyond single discipline software or cases, and integrate a range of patient problems within a comprehensive dental knowledge base. The approach is to use computer and hypermedia technology to weave together the disciplines of dentistry so that learning occurs in relation to patients, as they appear in the real world. The DentLE system prototype allows the learner to explore information in all the disciplines related to patient problems, as well as other information including "blind alleys" and results of curiosity.


Testing spatial understanding of anatomy. A system was designed to test the medical student's ability to recognize and locate anatomical cross-sections. The computer was used to prepare the data, present the test and track the user's responses. The nature of the test was such that it could be prepared, presented and used much more easily on the computer than on paper. The system was used successfully by anatomists and medical students.


Implementing guidelines in ambulatory practice. As we understand the process of ambulatory care better, the need to effectively implement standards of practice becomes more apparent. To facilitate successful use of practice guidelines, we have integrated an artificial intelligence system of Medical Logic Modules into our computerized medical record. A rule shell allows rapid development and prototyping of rules which can be practice reminders, information gathering utilities, or standing orders. A set of utilities allows non-programmer clinicians to develop and maintain the rule set. We will demonstrate these enhancements in the context of the comprehensive patient record.


The MEDLINE Button.

The MEDLINE Button. We have developed a computerized method for performing bibliographic searches directly from patient data involving five steps: 1) identifying specific patient data which raises a question in the mind of the user, 2) selection (from a list of generic questions) of a small number of questions which fit the selected patient data, 3) automated translation of the patient data into appropriate terms used for bibliographic indexing, 4) conversion of the question selected by the user into a search strategy, and 5) transfer of the search strategy to a search engine for a bibliographic database. We have modified the Columbia-Presbyterian Clinical Information System to experiment with this method. The first implementation converts patient diagnoses and procedures coded in ICD9-CM into Medical Subject Headings (MeSH) and searches Medline using BRS/Onsite. Challenges include development of a useful set of generic questions and translation from ICD9-CM to MeSH using the Unified Medical Language System (UMLS).


Health care informatics research implementation of the VA-DHCP Spanish version for Latin America. The VA DHCP, hospital computer program represents an integral solution to the complex clinical and administrative functions of any hospital world wide. Developed by the Department of Veterans Administration, it has until lately run exclusively in mainframe platforms. The recent implementation in PCs opens the opportunity for use in Latinamerica. Detailed description of the strategy for Spanish, local implementation in Colombia is made.


MailMinder: taming DHCP's mailman interface. While the Department of Veteran's Affairs Decentralized Hospital Computer Program (DHCP) is one of the most widely disseminated and successful hospital information systems in existence, it currently is accessed through a user interface which is not as mature as the rest of the system. This interface is a VT-100 compatible, character oriented interface using menus accessed by typed commands for feature access. This project demonstrated that a mature graphical user interface (MailMinder) can be successfully used as a "front-end" to DHCP. MailMinder is completely compatible with the existing unmodified DHCP electronic mail program, Mailman. MailMinder allows the user to be more efficient than the current interface and offers additional features over the current mail system. The program has undergone evaluation and limited deployment at five separate sites. The feature set of this program and its operation will be shown at this demonstration. The demonstration has implications for all current hospital information systems.


M NET: a statewide referring physician computer network. M NET, the Referring Physician Computer Network, is a joint project between the University of Michigan Medical Center (UMMC) and IBM. A graphical user interface was developed to allow referring physicians easy access to a variety of patient, clinical, and institutional data. File transfer mechanisms were created and current clinical database files and programs were enhanced and restructured to facilitate remote data transmission. M NET is currently installed in referring physician office sites across the state, with additional physician sites identified and program enhancements under development.


A cost effective expert system to assist physicians: epileptologists' assistant. While medical expert systems helped demonstrate that artificial intelligence was possible, few medical systems have been heralded as practical successes. We believe that expert systems will be practical successes if they cost effectively handle most of a physician's workload (i.e., routine care). To accomplish this goal, technology must appear invisible to the user; the system must be intuitive and anticipate users' needs. "Epileptologists' Assistant" is an example of our approach of combining a graphical user interface with an expert system and data base in a system to help in a routine specialty clinic. The goal is for two nurses and a physician to handle the workload of three physicians while increasing the quality of care. The current system reduces physician time by 66%. Our ultimate goal is to create a unified family of systems for medical specialties.


AIDA: an automated insulin dosage advisor. A prototype computer system utilising a model of carbohydrate metabolism linked to an expert system is described. The prototype which integrates quantitative and qualitative computational methodologies can be used to predict blood glucose profiles and adjust insulin doses in type I diabetic subjects.


CompuLung: a multimedia CBL on pulmonary auscultation. Cardio-pulmonary auscultation, a time honored art, is suffering a declining interest caused by competing diagnostic technology and inadequate training of physicians. Overreliance on diagnostic technology is expensive, not cost-effective and bound to lead to loss of our clinical heritage. We need novel methods to teach and revive this art. Computer-Based Learning (CBL), particularly multimedia supporting graphics plus sound-and-motion pictures, appears to be ideally suited for teaching and sharpening this skill. We present in this paper a multimedia CBL ("CompuLung"), that provides the user with a comprehensive and interactive tutorial on pulmonary auscultation.


Interactive query workstation: a demonstration of the practical use of UMLS knowledge sources. The Interactive Query Workstation (IQW) has been developed to provide clinicians with a uniform program interface for retrieving medical-related information from various computer-based information resources. These resources can vary in content (bibliographic databases, drug information, general medical text databases), function (article retrieval, differential diagnosis, drug interaction detection, or drug dosage and administration information), and media formats (local hard disk, CD-ROM, local area network, or distant telecommunication link). IQW allows modular addition of new resources as well as extension of previously installed resources. The National Library of Medicine's three Unified Medical Language System (UMLS) Knowledge Sources, the Metathesaurus (Meta), the Semantic Network, and the Information Sources Map (ISM) have been incorporated into many aspects of IQW. Meta provides information about medical terminology and aids IQW in isolating the basic concepts from a clinician's question. The Semantic Network provides information about the categorization of concepts and possible relations between concepts. It also assists IQW in determining which queries are appropriate for a set of concepts contained in the clinician's question. The ISM provides information about the content available from a computer-based resources and aids IQW in selecting an appropriate resource from which to collect information. The computer-based resource selection is performed without user intervention. This interactive demonstration shows an environment which increases the accessibility of medical information to clinicians by utilizing the three UMLS Knowledge Sources.


Professional DOC (PDOC): a software environment for authoring and consulting of electronic documentation. INTERACTIVE DIAGNOSIS and THERAPY: a medical application. Professional DOC (PDOC) is a software environment for electronic documentation authoring and consulting based on the Hypermedia technology. It allows to manage different kinds of information (pictures, sounds, texts, graphics, video) organized according to hyperstructures. The user-friendliness and effectiveness of its man-machine interface, and its availability on the most common hardware platforms makes it a suitable product for a very broad category of users. INTERACTIVE DIAGNOSIS AND THERAPY is an electronic medical book designed to help general practitioners to make diagnosis and treat patients in their daily clinic practice.


Computer-assisted diagnosis and teaching of disorders of electrolyte, acid-base, and water metabolism. Application of the tools of graphics, animation, sound and hypertext integrated with expert knowledge may help overcome the difficulties in teaching electrolyte and acid-base metabolism and its disorders. Using the Macintosh computer and the application, Hypercard we have developed two related programs with the following characteristics. Each contains graphic maps, consisting of a nomogram for plasma pH, PCO2 and HCO3 with zones representing physiological adaptation for each acid-base disorder (the Acid-Base map), and a nomogram illustrating relationships between plasma [Na+] and osmolality in hypo- and hypernatremic and hypo- and hypertonic states (the Sodium-Osmolality map). These are incorporated graphically and mathematically into each of the two Hypercard programs: The Acid-Base Diagnostician and The Osmotic Diagnostician. In the diagnostic module of each program, a differential diagnosis is developed for each of several zones on each map and, after obtaining additional user-entered clinical information, the program applies the relevant expert algorithms and presents the most likely diagnosis and differential diagnosis on screen and in printout. Each program has a teaching module involving text, hypertext, color graphics, digitized speech, and animation which demonstrate and discuss normal physiology, pathophysiology, and diagnostic criteria. The comprehensiveness and flexibility of the programs enable use by students at all levels, residents in medical and surgical disciplines, and physicians in many specialties.


Computer-based multimedia in plastic surgery education. Rapid developments in communications networks (cellular telephone, direct-link satellite, and international high-speed computer nets) and the continued success of affordable powerful personal computers (desktop, laptop and soon "palmtop" devices) have set the stage for educational materials accessible by electronic means. Computer-based multimedia are sophisticated audiovisual teaching materials built from digitized illustrations, photographs, audio and video recordings viewed by display on a computer screen. The computer interface allows interactive access to information, and connectivity to other sources of information. Computer programmability allows presentation of a single collection of information at different levels of sophistication (the "patient", "medical student" or "surgeon trainee" level, for example), to appeal to different viewer needs. The information may be electronically updated or changed whenever appropriate. This desktop exhibit demonstrates multimedia plastic surgery teaching materials with full-fidelity digital sound, three-dimensional computer graphics, and "picture-in-picture" video capabilities that we have developed since 1989. We have used these materials at St. Louis University for patient informed consent, and the education of medical students and surgical trainees. We are excited that similar multimedia teaching materials are now becoming commercially available in other fields of medical education, attesting to broadening interest among educators and publishers.


A multipurpose teaching workstation using expert systems, CD ROM and interactive laserdisc. This demonstration shows a multipurpose workstation used in a clinical teaching application which combines currently available software suitable for clinical diagnosis and teaching. The medical software includes QMR, Scientific American Medicine, the Slice of Life and generic video laserdisc authoring software developed at the University of Ottawa. The system allows a clinical instructor either in an individual or in a small group teaching setting on a ward or in a classroom, to access high quality differential diagnosis information via QMR, which is then supplemented by the text components of Scientific American Medicine on CD ROM, with video laserdisc of the appropriate anatomy, imagery and pathology provided by one of the various laserdiscs. The generic authoring software allows the instructor or students to construct subject related tutorial or testing modules either with or without video laserdisc support. The workstation uses DESQview as the multitasking environment to control the various resources. This program allows easy transfer from one application to another and allows for marking and pasting of text material into a study document. DESQview can also be used to script a specific learning sequence. The demonstration will show the interaction required to study a specific clinical problem and how this can be made into a meaningful multimedia experience with hardcopy for study purposes.


HTRAK, a computerized health maintenance tracking system for primary care. This presentation describes a computerized health maintenance tracking system for primary care designed to be linked to the practice billing system. Providers enter health maintenance data along with billing data on an encounter form. Physician and patient reminders are generated once a year for all patients regardless of appointment status. Multiple entry options are available and the frequency of procedures can be varied for individual patients. Summary reports are generated to assist compliance and quality assurance.


The Oncology Clinical Information System. This presentation provides an overview of the functions of the Oncology Clinical Information System (OCIS) focusing on three new applications. The first part of the presentation will describe the structure of OCIS and show the basic clinical decision-support aspects of the system on-line. The second part of the presentation will provide on-line demonstrations of three new applications: a sophisticated blood products ordering systems, a chemotherapy and treatment scheduling system, and a radiation therapy scheduling system.


HyperOncology: demonstration of an evolving comprehensive hypermedia-based workstation for the radiation oncologist. HyperOncology is a prototype hypermedia-based workstation designed for the practicing radiation oncologist. Individual patient records consist of linked demographic, clinical history, presentation, staging, course, laboratory and treatment data. Searching and sorting capabilities, navigational aids, information printing and archiving, plotting capability, and graphics and updating tools are available. Upon integration with an evolving knowledge base, HyperOncology will eventually become a comprehensive clinical database and information retrieval system in the specialty of radiation oncology.


Text-interpreter language for flexible generation of patient notes and instructions. An interpreted computer language has been developed along with a windowed user interface and multi-printer-support formatter to allow preparation of documentation of patient visits, including progress notes, prescriptions, excuses for work/school, outpatient laboratory requisitions, and patient instructions. Input is by trackball or mouse with little or no keyboard skill required. For clinical problems with specific protocols, the clinician can be prompted with problem-specific items of history, exam, and lab data to be gathered and documented. The language implements a number of text-related commands as well as branching logic and arithmetic commands. In addition to generating text, it is simple to implement arithmetic calculations such as weight-specific drug dosages; multiple branching decision-support protocols for paramedical personnel (or physicians); and calculation of clinical scores (e.g., coma or trauma scores) while simultaneously documenting the status of each component of the score. ASCII text files produced by the interpreter are available for computerized quality audit. Interpreter instructions are contained in text files users can customize with any text editor.


SCUT: clinical data organization for physicians using pen computers. The role of computers in assisting physicians with patient care is rapidly advancing. One of the significant obstacles to efficient use of computers in patient care has been the unavailability of reasonably configured portable computers. Lightweight portable computers are becoming more attractive as physician data-management devices, but still pose a significant problem with bedside use. The advent of computers designed to accept input from a pen and having no keyboard present a usable computer platform to enable physicians to perform clinical computing at the bedside. This paper describes a prototype system to maintain an electronic "scut" sheet. SCUT makes use of pen-input and background rule checking to enhance patient care. GO Corporation's PenPoint Operating System is used to implement the SCUT project.


Development of the cardiovascular system: an interactive video computer program. The major aim of this project is to provide interactive video computer based courseware that can be used by the medical student and others to supplement his or her learning of this very important aspect of basic biomedical education. Embryology is a science that depends on the ability of the student to visualize dynamic changes in structure which occur in four dimensions--X, Y, Z, and time. Traditional didactic methods, including lectures employing photographic slides and laboratories employing histological sections, are limited to two dimensions--X and Y. The third spatial dimension and the dimension of time cannot be readily illustrated using these methods. Computer based learning, particularly when used in conjunction with interactive video, can be used effectively to illustrate developmental processes in all four dimensions. This methodology can also be used to foster the critical skills of independent learning and problem solving.


CHARTLINE: providing bibliographic references relevant to patient charts using the UMLS Metathesaurus Knowledge Sources. A successful medical informatics program helps its users to match their information needs as closely and efficiently as possible to the capabilities of the system. CHARTLINE is a computer program whose input is a free text, "natural language" patient chart in ASCII format. Using the UMLS Metathesaurus Knowledge Sources, CHARTLINE can suggest bibliographic references relevant to the patient case described in the chart. The program does not attempt to "understand" the natural language content of the chart. CHARTLINE only recognizes UMLS Metathesaurus Main Concept terms (or their synonyms) as they occur in the medical text, since those terms represent the tokens used to index the literature. The program depends on user feedback to determine which topics of a large number of potentially relevant subjects are of interest to the user.


SCOUT: information retrieval from full-text medical literature. SCOUT is an expert system designed to aid the practicing physician in searching a full-text database of biomedical literature for information in the domain of oncology. In the clinical setting, an information-retrieval system needs to provide only a few relevant documents that address a patient-specific query. SCOUT models the expertise of an oncologist and an information specialist in a probabilistic inference system; it applies expert heuristics both in selecting the best source of information for a particular question and in developing an effective, source-specific search statement that retrieves only a minimal number of pertinent documents.


Design of an easy-to-use physician order entry system with support for nursing and ancillary departments. The Brigham Integrated Computing System (BICS) provides a broad range of clinical and administrative data-management functions for Brigham and Women's Hospital (BWH), a 720-bed major urban teaching hospital. We describe here the development of an inpatient order-entry system (BICS-OE) which is fully integrated into the BICS clinical environment. BICS-OE uses direct entry of orders by physicians to improve order response time and minimize transcription problems. BICS-OE includes a number of novel features to enhance its acceptance by physician users and its benefit to clinical practice in the hospital. Dual-mode input gives users a choice of full-screen assistance with ordering, or an intelligent text mode which provides rapid entry of orders by direct typing. An automated primary/on-call coverage by direct typing. An automated primary/on-call coverage list directs patient alerts and cosigning requests to the proper physician. Variable order sets allow a large group of orders to be stored and entered rapidly, even when some of the orders may change for different conditions. Multitasking allows the user to check prior orders and labs while concurrently entering new orders. The system permits a wide range of order checking and alerts.


The influence of high technology care on patients, their relatives and nurses. This article focuses on the potentially dichotomous relationship of caring for critically ill patients in a high technology environment. Does technology enhance or hinder the quality of patient care delivered by nurses in such an environment? The discussion within this article is initially at a societal level before focusing at an interpersonal level within a specific care setting. The author argues for finding a balance between high technology and humanity within the intensive care environment by highlighting the psychological impact that this may have on patients, relatives and nurses. Guidance as to how a balance may be achieved is also provided. Technology is an explicit theme within the text, whilst the concept of power that technology holds is discussed in an implicit manner.


Central venous catheter-related infection and dressing type. Localised infection and septicaemia are recognised complications of central venous catheterisation. This paper investigates the influence of dressing type on rates of infection by a review of published literature. Semi-permeable transparent dressings are widely used but evidence is accumulating that they increase the risk of infection as compared to dry gauze dressings.


Using the Mead model as a framework for nursing care. A model of nursing has no valid purpose unless it serves nurses to help make their nursing better (Fawcett, 1989). The Mead model formed the basis for nursing care of Jason, a young patient who sustained a head injury, a puncture wound and lacerations to his face, in the study presented here. Examination of the Mead Model of nursing is followed by an account of why this model was used in preference to others as a framework for Jason's care. Three components of his nursing care--wound care, communication, involvement of relatives--are discussed in relation to both the model and current knowledge. It was concluded that as a structured way of planning and giving care, the Mead model lacks adequate guidelines. A less experienced nurse using the Mead model may overlook certain aspects of care, an experienced nurse may use his/her knowledge to give high standard care using research-based information. However, models need to be tested so they may be rejected or modified as guidelines for care in this case in the United Kingdom, within a welfare-orientated society.


Potential hazards of tracheobronchial suctioning. Tracheobronchial suctioning is a routine practice frequently carried out in intensive care units (ICUs). It is required when the normal coughing mechanism is inadequate or disrupted; for example, where there is underlying respiratory or neurological disease, or where the cough is deliberately suppressed by sedative, muscle relaxants or anaesthetic agents while a patient is undergoing intermittent positive pressure ventilation. The procedure is carried out via a nasotracheal, orotracheal or tracheostomy tube. During the performance of this intervention, the skilled nurse is aware of the risks to which the patient is exposed and endeavours to prevent or minimise possible complications. In the following account of complications that may occur during or as a result of the procedure these have been classified as immediate, intermediate and later complications, as shown in Table 2. The purpose is to stimulate greater awareness of the hazards involved in this common everyday practice in intensive care units.


Organ donation in intensive care--a look at the ethical issues. This paper is based on consideration of the ethical issues surrounding organ donation. This emotive subject has far-reaching implications concerning both donation and transplantation but the purpose in this paper is to deal specifically with issues related to cadaveric organ donation and how they concern nurses in an intensive care unit (ICU). A brief, general description of both ethics and organ donation is followed by a discussion of the issues surrounding the donor himself, including the diagnosis of brainstem death, the donor's family, and the nursing and medical implications. Legal, social and economic factors are considered with the aim of highlighting ethical areas but not necessarily providing answers to the questions raised.


Secondary transportation of critically ill people--implications for nurses and the need for specialist training. Much has been published about the techniques and procedures involved in secondary transportation of the critically ill, together with the complications and limitations that arise during the transfer procedure. However, little has been written or published concerning the implications to the staff accompanying the patient and it is acknowledged that this has yet to be properly addressed (Runcie et al 1991). Transfer of critically ill patients with complex problems places staff in a unique patient-care environment, placing a tremendous responsibility on the individuals concerned and puts them in a very vulnerable position, especially if an emergency develops during transit. Recognition must be made of this specialist role and the commitment involved. Nurses, who form a vital part of the transfer team, cannot be expected to adapt easily to this form of advanced care without some form of training, which should be undertaken before individual nurses are allowed to perform this most important and responsible role.


Chaos theory--a useful addition to the critical care curriculum? Chaos theory (non-linear dynamics) is a relatively new mathematical concept. It shows that many apparently random processes and structures have in fact a simple underlying order. The theory is being applied increasingly to explain physiological processes and epidemiological findings, as well as in non-health areas, such as modelling weather systems. The author argues for its future inclusion as a modular option in post-registration critical care/high technology nursing courses.


How nurses can ensure the sounds patients hear have a positive rather than negative effect upon recovery and quality of life. A number of studies imply that control of a patient's auditory environment can generate an improvement in recovery and quality of life. The evidence suggests nurses have the ability to control their patients' auditory environment and in so doing can reduce factors which contribute to physical and psychological instability. Through communication nurses are able to humanise treatment, deter ignorance and cement personal relationships of mutual trust between patients and their families. Reference to nursing unconscious patients in Intensive Therapy Units (ITU) indicates how nurses can relate theory to practice and ensure a positive rather than negative experience of recovery by regulating and influencing the sounds patients hear.


Ethical dilemmas and solutions for risk assessment scientists. A sample survey of U.S. scientists who belong to the Society for Risk Analysis (SRA) was made to ascertain their observations of unethical behavior in the workplace and their opinions of the likely success of programs to prevent misconduct. SRA, an international organization with almost 1,700 U.S. members, includes toxicologists, epidemiologists, industrial hygienists, engineers, and social scientists, as well as experts in exposure assessment, statistics, and risk communications. Respondents reported relatively low rates of clearly unethical acts such as data destruction and fabrication (7%); however, 21% reported at least one observation of plagiarism. Reporting of other problematic behaviors ranged from less than 4% for human subjects violations to 51% observing deliberate overstatement of positive and deliberate understatement of negative results. SRA members did not think that government intervention would be effective in reducing misconduct. They were more supportive of formal education, seminars, videotapes, and a hotline that could be called for advice. We offer suggestions to ISEA and its members for developing a proactive approach to ethical misconduct.