Computer Decision Support Changes Physician Practice But Not Knowledge Regarding Autism Spectrum Disorders.

OBJECTIVE: To examine whether adding an autism module promoting adherence to clinical guidelines to an existing computer decision support system (CDSS) changed physician knowledge and self-reported clinical practice. METHODS: The CHICA (Child Health Improvement through Computer Automation) system, a CDSS, was enhanced with a module to improve management of autism in 2 of the 4 community pediatric clinics using the system. We examined the knowledge and beliefs of pediatric users using cross-sectional surveys administered at 3 time points (baseline, 12 months and 24 months post-implementation) between November 2010 and January 2013. Surveys measured knowledge, beliefs and self-reported practice patterns related to autism. RESULTS: A total of 45, 39, and 42 pediatricians responded at each time point, respectively, a 95-100% response rate. Respondents' knowledge of autism and perception of role for diagnosis did not vary between control and intervention groups either at baseline or any of the two post-intervention time points. At baseline, there was no difference between these groups in rates in the routine use of parent-rated screening instruments for autism. However, by 12 and 24 months post-implementation there was a significant difference between intervention and control clinics in terms of the intervention clinics consistently screening eligible patients with a validated autism tool. Physicians at all clinics reported ongoing challenges to community resources for further work-up and treatment related to autism. CONCLUSIONS: A CDSS module to improve primary care management of ASD in pediatric practice led to significant improvements in physician-reported use of validated screening tools to screen for ASDs. However it did not lead to corresponding changes in physician knowledge or attitudes.

Leveraging electronic tablets for general pediatric care: a pilot study.

BACKGROUND: We have previously shown that a scan-able paper based interface linked to a computerized clinical decision support system (CDSS) can effectively screen patients in pediatric waiting rooms and support the physician using evidence based care guidelines at the time of clinical encounter. However, the use of scan-able paper based interface has many inherent limitations including lacking real time communication with the CDSS and being prone to human and system errors. An electronic tablet based user interface can not only overcome these limitations, but may also support advanced functionality for clinical and research use. However, use of such devices for pediatric care is not well studied in clinical settings. OBJECTIVE: In this pilot study, we enhance our pediatric CDSS with an electronic tablet based user interface and evaluate it for usability as well as for changes in patient questionnaire completion rates. METHODS: Child Health Improvement through Computers Leveraging Electronic Tablets or CHICLET is an electronic tablet based user interface. It is developed to augment the existing scan-able paper interface to our CDSS. For the purposes of this study, we deployed CHICLET in one outpatient pediatric clinic. Usability factors for CHICLET were evaluated via caregiver and staff surveys. RESULTS: When compared to the scan-able paper based interface, we observed an 18% increase or 30% relative increase in question completion rates using CHICLET. This difference was statistically significant. Caregivers and staff survey results were positive for using CHICLET in clinical environment. CONCLUSIONS: Electronic tablets are a viable interface for capturing patient self-report in pediatric waiting rooms. We further hypothesize that the use of electronic tablet based interfaces will drive advances in computerized clinical decision support and create opportunities for patient engagement.

Actionable recommendations in the Bright Futures child health supervision guidelines.

BACKGROUND: With the growing use of electronic health record systems, there is a demand for an electronic version of the leading American pediatric preventive care guideline, Bright Futures. As computer implementation requires actionable recommendations, it is important to assess to what degree Bright Futures meets criteria for actionability. OBJECTIVES: We aimed to 1) determine the number of actionable recommendations in the current edition of Bright Futures and 2) to recommend a specific format for representing an important class of guidelines in a way that better facilitates computer implementation. METHODS: We consolidated all action statements in Bright Futures into recommendations. We then used two dimensions (decidability and executability) in the Guideline Implementability Appraisal v 2.0 (GLIA) to determine the actionability of the recommendations. Decidability means the recommendation states precisely under what conditions to perform those actions. Executability means actions are stated specifically, unambiguously and in sufficient detail. The results were presented in a figure titled Service Interval Diagram (SID), describing actionable recommendations, age intervals during which they are applicable, and how frequently they should occur in that interval. RESULTS: We consolidated 2161 action items into 245 recommendations and identified 52 that were actionable (21%). Almost exclusively, these recommendations addressed screening, such as newborn metabolic screening, or child safety, such as car seat use. A limited number (n=13) of recommendations for other areas of anticipatory guidance were also actionable. No recommendations on child discipline, family function or mental health met our criteria for actionability. The SID representing these recommendations is presented in a figure. CONCLUSION: Only a portion of the Bright Futures Guidelines meets criteria for actionability. Substantial work lies ahead to develop most recommendations for anticipatory guidance into a computer implementable format.

Gender differences in risk attitudes.

PURPOSE: A rich literature has documented gender-based differences in health care utilization and outcomes. The role of risk attitude in explaining the variations is limited at best. This study examines gender differences in health utilities and risk attitudes. METHODOLOGY: Data on 13 health states were collected from 629 students via questionnaires at the Ben-Gurion University of the Negev in 2005. From each respondent, we assessed utilities for a subset of health states, using Time Trade-Off and Standard Gamble. A risk attitude coefficient was calculated for each respondent as a function of their utilities for all outcomes assessed. The risk coefficient derived from a closed-form utility model for men was compared to that of women using the t-statistic. FINDINGS: There was a statistically significant difference in the risk attitudes of men and women. Men had a concave utility function, representing risk aversion, while women had a near linear utility function, suggesting that women are risk neutral. PRACTICAL/SOCIAL IMPLICATIONS: Differences in risk attitude may be an important contributor to gender-based disparities in health services utilization. More research is needed to assess its full impact on decision-making in health care.

Understanding why clinicians answer or ignore clinical decision support prompts.

INTRODUCTION: The identification of key factors influencing responses to prompts and reminders within a computer decision support system (CDSS) has not been widely studied. The aim of this study was to evaluate why clinicians routinely answer certain prompts while others are ignored. METHODS: We utilized data collected from a CDSS developed by our research group--the Child Health Improvement through Computer Automation (CHICA) system. The main outcome of interest was whether a clinician responded to a prompt. RESULTS: This study found that, as expected, some clinics and physicians were more likely to address prompts than others. However, we also found clinicians are more likely to address prompts for younger patients and when the prompts address more serious issues. The most striking finding was that the position of a prompt was a significant predictor of the likelihood of the prompt being addressed, even after controlling for other factors. Prompts at the top of the page were significantly more likely to be answered than the ones on the bottom. CONCLUSIONS: This study detailed a number of factors that are associated with physicians following clinical decision support prompts. This information could be instrumental in designing better interventions and more successful clinical decision support systems in the future.

Pediatric injury prevention counseling: an observational study of process and content.

OBJECTIVES: To describe routine injury prevention counseling; to observe how three visit components - printed prompts, parent remarks, and parent behaviors - affect such counseling; to describe the process and content of discussions about car seats as an example of routine injury prevention. METHODS: A total of 128 well-child visits of children under 7 months of age to a university pediatric clinic were videotaped (76% of eligible visits). RESULTS: Three injury topics were mentioned, on an average, per visit. Parents or caregivers rarely introduced injury topics (5%). Physicians frequently introduced those topics listed on age-specific prompting sheets (73%). Car seat counseling typically began with a physician's question (82%). Most asked simply about ownership or use (93%). Few addressed difficult issues, such as consistency of use (11%). CONCLUSIONS: Physicians bring up the injury topics that are prompted. However, most discussion is superficial. Printed prompts that address counseling process as well as content might be beneficial.

A gap-junction-mediated signal, rather than an external paracrine factor, predominates during meiotic induction in isolated mouse oocytes.

This study was carried out to compare the possible role of a secreted paracrine factor versus that of a gap-junction-transmitted signal in mediating meiotic induction in isolated mouse oocytes from PMSG-primed, immature mice. In the first set of experiments, oocyte-cumulus cell complexes (OCC) were pretreated for 3 h with 2 mM dbcAMP or FSH, washed, and the oocytes then cultured for 17-18 h in 40 microl drops containing either 300 microM dbcAMP or 4 mM hypoxanthine (HX). Each set of pretreated oocytes was cultured under three different conditions: (1) intact cumulus-cell-enclosed oocytes (CEO); (2) denuded oocytes (DO), cultured alone after removal of cumulus cells; and (3) co-cultured cumulus cells and oocytes (CC/DO), where the cumulus cells were removed in the same drop with a mouth-operated pipette and cultured alongside the oocytes. When pretreated with high dbcAMP or FSH, maturation was stimulated in CEO when cultured in either inhibitor (by 41.4-53.7%). Pretreatment failed to affect the maturation rate in DO. DO maturation was not altered appreciably by co-cultured cumulus cells when arrest was maintained with dbcAMP. However, an increase in maturation of 21-23% was observed in CC/DO in the HX-containing cultures that was not dependent on prior treatment with a meiosis-inducing stimulus. When DO were co-cultured with intact, FSH-treated OCC, there was no evidence of a positive factor secreted by the stimulated complexes, despite the fact that oocytes within the OCC were induced to resume maturation. In a second series of experiments the gap junction inhibitor, 18alpha-glycyrrhetinic acid (GA), was utilised. An initial experiment determined that GA dose-dependently blocked OCC metabolic coupling (0.2% coupling at 10 microM compared with 13.6% in controls). When HX-arrested CEO and DO were cultured for 17-18 h in medium containing increasing concentrations of GA, meiotic maturation was induced in CEO but not DO, suggesting that the cumulus cells provided a positive stimulus in the absence of functional gap junctional communication. No effect of GA was seen in dbcAMP-arrested oocytes. A kinetics experiment showed that when CEO were cultured in dbcAMP +/- FSH, meiotic induction was initiated after 3 h and germinal vesicle breakdown reached 60% by 6 h. When GA was added to the cultures at different times after the initiation of culture (0, 2, 3, 4 and 5 h), meiotic induction was immediately blocked. In addition, measurement of OCC coupling revealed that no reduction in coupling occurred during this induction period in the absence of GA. It is concluded that cumulus cells can secrete a positive factor, but that this is normally overridden by inhibitory influences transmitted through the gap junction pathway in intact complexes. Furthermore, upon exposure of complexes to a meiosis-inducing stimulus, a positive gap-junction-mediated signal now predominates to trigger germinal vesicle breakdown, and this signal is utilised throughout the induction period.

Meiosis-activating sterol and the maturation of isolated mouse oocytes.

This study was carried out to examine the effects of the meiosis-activating C(29) sterol, 4,4-dimethyl-5 alpha-cholesta-8,14, 24-trien-3 beta-ol (FF-MAS), on mouse oocyte maturation in vitro. Cumulus cell-enclosed oocytes (CEO) and denuded oocytes (DO) from hormonally primed, immature mice were cultured 17-18 h in minimum essential medium (MEM) containing 4 mM hypoxanthine plus increasing concentrations of FF-MAS. The sterol induced maturation in DO with an optimal concentration of 3 microg/ml but was without effect in CEO, even at concentrations as high as 10 microg/ml. Some stimulation of maturation in hypoxanthine-arrested CEO was observed when MEM was replaced by MEMalpha. Interestingly, the sterol suppressed the maturation of hypoxanthine-arrested CEO in MEM upon removal of glucose from the medium. FF-MAS also failed to induce maturation in DO when meiotic arrest was maintained with dibutyryl cAMP (dbcAMP). The rate of maturation in FF-MAS-stimulated, hypoxanthine-arrested DO was slow, as more than 6 h of culture elapsed before significant meiotic induction was observed, and this response required the continued presence of the sterol. Although the oocyte took up radiolabeled lanosterol, such accumulation was restricted by the presence of cumulus cells. In addition, lanosterol failed to augment FSH-induced maturation and was even inhibitory at a high concentration. Moreover, the downstream metabolite, cholesterol, augmented the inhibitory action of dbcAMP on maturation in both CEO and DO. Two inhibitors of 14 alpha-demethylase, ketoconazole, and 14 alpha-ethyl-5 alpha-cholest-7-ene-3 beta, 15 alpha-diol that can suppress FF-MAS production from lanosterol failed to block consistently FSH-induced maturation. These results confirm the stimulatory action of FF-MAS on hypoxanthine-arrested DO but do not support a universal meiosis-inducing function for this sterol.

Protein kinase C and meiotic regulation in isolated mouse oocytes.

In this study, the possible role of protein kinase C (PKC) in mediating both positive and negative actions on meiotic maturation in isolated mouse oocytes has been examined. When cumulus cell-enclosed oocytes (CEO) were cultured for 17-18 hr in a medium containing 4 mM hypoxanthine (HX) to maintain meiotic arrest, each of the five different activators and five different antagonists of PKC stimulated germinal vesicle breakdown (GVB) in a dose-dependent fashion. One of the activators, phorbol-12-myristate 13-acetate (PMA), also triggered GVB in CEO arrested with isobutylmethylxanthine or guanosine, but not in those arrested with dibutyryl cyclic AMP. When denuded oocytes (DO) were cultured for 3hr in inhibitor-free medium, all PKC activators suppressed maturation (<10% GVB compared to 94% in controls), while the effect of PKC antagonists was negligible. Four of the five antagonists reversed the meiosis-arresting action of HX in DO. PMA transiently arrested the spontaneous maturation of both CEO and DO, with greater potency in DO. The stimulatory action of PMA in HX-arrested oocytes was dependent on cumulus cells, because meiotic induction occurred in CEO but not DO. PKC activators also preferentially stimulated cumulus expansion when compared to antagonists. A cell-cell coupling assay determined that the action of PMA on oocyte maturation was not due to a loss of metabolic coupling between the oocyte and cumulus oophorus. Finally, Western analysis demonstrated the presence of PKCs alpha, beta1, delta, and eta in both cumulus cells and oocytes, but only PKC epsilon was detected in the cumulus cells. It is concluded that direct activation of PKC in the oocyte suppresses maturation, while stimulation within cumulus cells generates a positive trigger that leads to meiotic resumption.

Energy substrates and the completion of spontaneous meiotic maturation.

This study was carried out to examine how different combinations of pyruvate and glucose affect spontaneous meiotic maturation of cumulus-cell-enclosed mouse oocytes (CEO) to metaphase II (MII). Most experiments used an open system in which oocytes were cultured in 1 ml medium in plastic tubes. Initial experiments examined the dose response effects of pyruvate or glucose alone in the presence or absence of 2 mM glutamine. When medium lacked both pyruvate and glucose, more than 91% of the oocytes died in glutamine-free medium during 15 h of culture; viability was restored with the addition of glutamine, but only 11% of the CEO reached MII. In the absence of glutamine, 62-68% of oocytes completed maturation in 0.23-2.3 mM pyruvate, while 44-60% MII was observed in 0.55-27.8 mM glucose. The addition of glutamine to these cultures had a general suppressive effect on the completion of maturation. When glucose was added to pyruvate-containing cultures, the combination of 1 mM pyruvate/5.5 mM glucose was most effective in supporting maturation (about 90% MII), with little effect of glutamine. No further increase in maturation was observed when glucose was increased five-fold (to 27.8 mM). The positive effect of glucose was in part attributed to stimulation of glycolysis and increased production of pyruvate, since a reduced culture volume (8 microl), which allows the accumulation of secreted pyruvate, improved maturation in glucose-containing, but not pyruvate-containing, medium, and FSH, which stimulates glycolysis, increased progression to MII in glucose-containing, but not pyruvate-containing, medium. Yet these results also suggest that glucose has a beneficial effect on maturation apart from simple provision of pyruvate. The pyruvate effect was directly on the oocyte, because denuded oocytes responded more effectively than CEO to this energy substrate. The highest percentage of MII oocytes (96-97%) occurred in microdrop cultures containing glucose but lacking glutamine. These results indicate that glutamine supports oocyte viability but is not an adequate energy source for the completion of spontaneous meiotic maturation and may be detrimental. In addition, while pyruvate and glucose alone can each support meiotic progression of CEO to MII, optimal maturation requires the provision of both substrates to the culture medium when a large volume (1 ml) is used. It is concluded that careful attention to specific energy substrate supplementation and culture volume is important to optimise spontaneous meiotic maturation in vitro.

Mining association rules from a pediatric primary care decision support system.

The purpose of this study was to apply an unsupervised data mining algorithm to a database containing data collected at the point of care for clinical decision support. The data set was taken from the Child Health Improvement Program (CHIP), a preventive services tracking and reminder system in use at the University of North Carolina. The database contains over 30,000 visits. We used a previously described pattern discovery algorithm to extract 2nd and 3rd order association rules from the data and reviewed the literature two see if the associations had been described before. The algorithm discovered 16 2nd order associations and 103 3rd order associations. The 3rd order associations contained no new information. The 2nd order associations demonstrated a covariance among a range of health risk behaviors. Additionally, the algorithm discovered that both tobacco smoke exposure and chronic cardiopulmonary disease are associated with failure on developmental screens. These relationships have been described before and have been attributed to underlying poverty. The work demonstrates the ability of unsupervised data mining by rule association on sparse clinical data to discover clinically important associations. However, many associations may be previously known or explained by confounding variables.

Comparing user acceptance of a computer system in two pediatric offices: a qualitative study.

The purpose of this qualitative study was to examine user acceptance of a clinical computer system in two pediatric practices in the southeast. Data were gathered through interviews with practice and IS staff, observations in the clinical area, and review of system implementation records. Five months after implementation, Practice A continued to use the system but Practice B had quit using it because it was unacceptable to the users. The results are presented here, in relation to a conceptual framework, which was originally developed to describe the process of successful implementation of research findings into practice. Five main themes were identified relative to the differences in user acceptance at the two practices: 1) Benefits versus expense of system use varied, 2) Organizational cultures differed, 3) IS staff's relationship with practices differed, 4) Post-implementation experiences differed, and 5) Transfer of technology from the academic center to private practice proved challenging in Practice B. The findings indicate a need for the development and validation of tools to measure healthcare organizational climate and readiness for change.

Adenosine blocks hormone-induced meiotic maturation by suppressing purine de novo synthesis.

We have examined adenosine (Ado) suppression of FSH-induced germinal vesicle breakdown (GVB) and its relationship to purine de novo synthesis. Oocyte-cumulus cell complexes (OCC) from PMSG-primed, immature mice were cultured 17-18 hr in medium containing 4 mM hypoxanthine (HX) or 300 microM dibutyryl cAMP (dbcAMP) to maintain meiotic arrest, and FSH was added to stimulate meiotic maturation. In the absence of FSH, Ado (1-250 microM) had no effect in dbcAMP-arrested oocytes but dose-dependently suppressed maturation in HX-treated oocytes. FSH-induced maturation was prevented by Ado, though more effectively in dbcAMP-supplemented cultures. Ado affected the magnitude, but not the kinetics pattern, of the response to FSH. Inosine also blocked meiotic induction, but only in dbcAMP-arrested oocytes. Purine de novo synthesis was nearly doubled in OCC by FSH treatment, and this response was completely prevented by Ado. FSH had no effect on HX salvage, although Ado reduced this activity by 98%. Inosine effects on metabolism were intermediate between the control and Ado groups. Experiments with radiolabeled energy substrates showed that Ado suppressed FSH activation of the pentose phosphate pathway but did not prevent significant activation of glycolysis or oxidation of pyruvate. Finally, in cultured follicles from primed mice, hCG-induced maturation was blocked by Ado as effectively as by the purine de novo synthesis inhibitor, azaserine. It is concluded that Ado has an inhibitory action on hormone-induced maturation that is due, at least in part, to suppression of glucose metabolism, leading to compromised purine de novo synthesis.

A cost-effectiveness analysis of newborn hearing screening strategies.

CONTEXT: Congenital hearing loss affects between 1 and 3 out of every 1,000 children. Screening of all neonates has been made possible by the development of portable automated devices. Universal screening is a 2-stage screening process using automated transient-evoked otoacoustic emissions, followed when indicated by automated auditory brain response testing. Targeted screening reserves the 2-stage screening process for those infants at risk for congenital hearing loss. OBJECTIVE: To compare the expected costs and benefits of targeted screening with universal screening for the detection of significant bilateral congenital hearing loss. DESIGN: Cost-effectiveness analysis from the health care system perspective. including costs directly related to screening and initial follow-up evaluation. MAIN OUTCOME MEASURES: Number of cases identified, number of false positives, and cost per case. RESULTS: For every 100,000 newborns screened, universal screening detects 86 of 110 cases of congenital hearing loss, at a cost of $11,650 per case identified. Targeted screening identifies 51 of 110 cases, at $3,120 per case identified. Universal screening produces 320 false-positive results, 304 more than targeted screening. Switching to universal screening from targeted screening would cost an additional $23, 930 for each extra case detected. CONCLUSIONS: Universal screening detects more cases of congenital hearing loss, at the expense of both greater cost and more false-positive screening results. Little is known about the negative impact of false-positive screening and about the benefits of early intervention for congenital hearing loss. Those who advocate adoption of universal screening should be aware not only of the direct costs of universal screening, but of the indirect costs and strategies to increase the benefits of screening.

Parents' utilities for outcomes of occult bacteremia.

OBJECTIVE: To describe parents' values for outcomes of occult bacteremia using utility assessment, a quantitative method that incorporates risk preference. DESIGN: Computer-based utility assessment interview. SETTING: Urban children's hospital pediatric emergency department with 50 000 visits annually. PARTICIPANTS: Convenience sample of parents presenting with a child between 3 and 36 months. MAIN OUTCOME MEASURE: Parents' utility values for 8 outcomes from treatment of occult bacteremia: blood drawing, localized infection, hospitalization for antibiotics, meningitis with recovery, meningitis resulting in deafness, minor brain damage, severe brain damage, and death. RESULTS: Ninety-four subjects successfully completed the interview. Mean utilities were 0.9974 for blood drawing, 0.9941 for local infection, 0.9921 for hospitalization, 0.9768 for meningitis with recovery, 0.8611 for deafness, 0.7393 for minor brain damage, 0.3903 for severe brain damage, and 0.0177 for death. All values were significantly different from those that immediately preceded and succeeded (P<.0001), except for local infection vs hospitalization (P = .14). Median utilities for blood drawn, local infection, and hospitalization were 1. There were no significant differences among utilities of parents who presented with a febrile child (temperature > or =39 degrees C), or an afebrile child (temperature <39 degrees C). There were also no significant differences among utilities regardless of whether parents had children with prior experience with the outcomes. CONCLUSIONS: Assessment of utilities for outcomes of occult bacteremia yielded extremely high mean and median values for outcomes without permanent sequelae. This suggests that parents presenting to an emergency department may rationally prefer painful transient experiences, including venipuncture, for their children rather than risk even rare chances of severe outcomes.

A systematic review of vision screening tests for the detection of amblyopia.

OBJECTIVE: To review the test characteristics and the quality of evidence regarding available screening tests for the detection of amblyopia in preschool-aged children to help primary care practitioners select a screening strategy. DESIGN: Systematic review of published studies. DATA SOURCES: The MEDLINE database was searched from 1966 through January 1999 using a broad and inclusive strategy. A total of 9551 citations were identified. STUDY SELECTION: All studies that compared the results of commercially available screening tests in preschool-aged children to ophthalmologic examination. DATA EXTRACTION: The setting of the study, the age of the population, the type of screening test, criteria for a positive screen, criteria for the ophthalmologic examination, test characteristics, and measures of reliability were abstracted by 2 reviewers for each selected study. DATA SYNTHESIS: Four eligible articles were identified that studied the test characteristics of 3 screening tests. None of these studies were performed in a primary care setting. Each study used different criteria for failure of the ophthalmologic examination. None of the studies measured observer or test reliability. CONCLUSIONS: Few high-quality data exist regarding the performance of preschool vision screening. Important future work should include the development of a consensus gold standard ophthalmologic examination and evaluation of screening tests in the primary care setting.

Scoring performance on computer-based patient simulations: beyond value of information.

As computer based clinical case simulations become increasingly popular for training and evaluating clinicians, approaches are needed to evaluate a trainee's or examinee's solution of the simulated cases. In 1997 we developed a decision analytic approach to scoring performance on computerized patient case simulations, using expected value of information (VOI) to generate a score each time the user requested clinical information from the simulation. Although this measure has many desirable characteristics, we found that the VOI was zero for the majority of information requests. We enhanced our original algorithm to measure potential decrements in expected utility that could result from using results of information requests that have zero VOI. Like the original algorithm, the new approach uses decision models, represented as influence diagrams, to represent the diagnostic problem. The process of solving computer based patient simulations involves repeated cycles of requesting and receiving these data from the simulations. Each time the user requests clinical data from the simulation, the influence diagram is evaluated to determine the expected VOI of the requested clinical datum. The VOI is non-zero only it the requested datum has the potential to change the leading diagnosis. The VOI is zero when the data item requested does not map to any node in the influence diagram or when the item maps to a node but does not change the leading diagnosis regardless of it's value. Our new algorithm generates a score for each of these situations by modeling what would happen to the expected utility of the model if the user changes the leading diagnosis based on the results. The resulting algorithm produces a non-zero score for all information requests. The score is the VOI when the VOI is non-zero It is a negative number when the VOI is zero.

Student and faculty performance in clinical simulations with access to a searchable information resource.

In this study we explore how students' use of an easily accessible and searchable database affects their performance in clinical simulations. We do this by comparing performance of students with and without database access and compare these to a sample of faculty members. The literature supports the fact that interactive information resources can augment a clinician's problem solving ability in small clinical vignettes. We have taken the INQUIRER bacteriological database, containing detailed information on 63 medically important bacteria in 33 structured fields, and incorporated it into a computer-based clinical simulation. Subjects worked through the case-based clinical simulations with some having access to the INQUIRER information resource. Performance metrics were based on correct determination of the etiologic agent in the simulation and crosstabulated with student access of the information resource; more specifically it was determined whether the student displayed the database record describing the etiologic agent. Chi-square tests show statistical significance for this relationship (chi 2 = 3.922; p = 0.048). Results support the idea that students with database access in a clinical simulation environment can perform at a higher level than their counterparts who lack access to such information, reflecting favorably on the use of information resources in training environments.