Clinicians are from Mars and pathologists are from Venus.

CONTEXT: Text reports convey critical medical information from pathologists, radiologists, and subspecialty consultants. These reports must be clear and comprehensible to avoid medical errors. Pathologists have paid much attention to report completeness but have ignored the corresponding issue of report comprehension. This situation presents an increasingly serious potential problem. As laboratories are consolidated and as reports are disseminated in new ways (eg, via the World Wide Web), the target audience becomes more diverse and less likely to have any contact with pathologists beyond the written reports themselves. OBJECTIVE: To compare clinician comprehension with pathologist intent in written pathology reports. METHODS: Typical surgical pathology reports relevant to surgeons and covering a range of specimen complexity were taken from our hospital files. Questionnaires based on these cases were administered open-book-examination style to surgical attending physicians and trainees during surgical conferences at an academic medical center. MAIN OUTCOME MEASURES: Scores from questionnaires. RESULTS: Surgeons misunderstood pathologists' reports 30% of the time. Surgical experience reduced but did not eliminate the problem. Streamlined report formatting exacerbated the problem. CONCLUSIONS: A communication gap exists between pathologists and surgeons. Familiarity with report format and clinical experience help reduce this gap. Paradoxically, stylistic improvements to report formatting can interfere with comprehension and increase the number of misunderstandings. Further investigation is required to reduce the number of misunderstandings and, thus, medical errors.

Opportunities for and challenges of computerisation.

Information technology offers many potential advantages over paper for the storage and retrieval of patients' data. Enthusiasts predict that soon all records will be stored and viewed on computer, but others are more sceptical. The failure of some computer-based records may be due to poor information design. This paper explores how computers broaden the range of design options but points out that more attention to design is required for computer-based than for paper-based records.

Summarizing clinical psychiatric data.

The authors propose a method of summarizing clinical data to serve patient care. The proposed one-page summary uses diverse visual presentations of data, including small graphs for ratings and drug dosages, time lines for clinic visits and hospital stays, and genograms for inherited illness, as well as a textual presentation of recent clinical notes. The summary depicts a patient's recent and lifetime clinical experience. It allows the viewer to assess relationships between interventions and outcomes for psychiatric and medical problems. Computerized patient information systems, which are increasingly being used, can present data in virtually any form. The authors hope to encourage mental health professionals to reshape psychiatric records.

Visualizing the logic of a clinical guideline: a case study in childhood immunization.

IMM/Graph is a visual model designed to help knowledge-base developers understand and refine the guideline logic for childhood immunization. The IMM/Graph model is domain-specific and was developed to help build a knowledge-based system that makes patient-specific immunization recommendations. A "visual vocabulary" models issues specific to the immunization domain, such as (1) the age a child is first eligible for each vaccination dose, (2) recommended, "past due" and maximum ages, (3) minimum waiting periods between doses, (4) the vaccine brand or preparation to be given, and (5) the various factors affecting the time course of vaccination. Several lessons learned in the course of developing IMM/Graph include the following: (1) The intended use of the model may influence the choice of visual presentation; (2) There is a potentially interesting interplay between the use of visual and textual information in creating the visual model; (3) Visualization may help a development team better understand a complex clinical guideline and may also help highlight areas of incompleteness.

Lessons learned from a pilot implementation of the UMLS information sources map.

OBJECTIVE: To explore the software design issues involved in implementing an operational information sources map (ISM) knowledge base (KB) and system of navigational tools that can help medical users access network-based information sources relevant to a biomedical question. DESIGN: A pilot biomedical ISM KB and associated client-server software (ISM/Explorer) have been developed to help students, clinicians, researchers, and staff access network-based information sources, as part of the National Library of Medicine's (NLM) multi-institutional Unified Medical Language System (UMLS) project. The system allows the user to specify and constrain a search for a biomedical question of interest. The system then returns a list of sources matching the search. At this point the user may request 1) further information about a source, 2) that the list of sources be regrouped by different criteria to allow the user to get a better overall appreciation of the set of retrieved sources as a whole, or 3) automatic connection to a source. RESULTS: The pilot system operates in client-server mode and currently contains coded information for 121 sources. It is in routine use from approximately 40 workstations at the Yale School of Medicine. The lessons that have been learned are that: 1) it is important to make access to different versions of a source as seamless as possible, 2) achieving seamless, cross-platform access to heterogeneous sources is difficult, 3) significant differences exist between coding the subject content of an electronic information resource versus that of an article or a book, 4) customizing the ISM to multiple institutions entails significant complexities, and 5) there are many design trade-offs between specifying searches and viewing sets of retrieved sources that must be taken into consideration. CONCLUSION: An ISM KB and navigational tools have been constructed. In the process, much has been learned about the complexities of development and evaluation in this new environment, which are different from those for Gopher, wide area information servers (WAIS), World-Wide-Web (WWW), and MOSAIC resources.

Navigating the Internet.

Navigating any complex set of information resources requires tools for both browsing and searching. A number of tools are available today for using Internet resources, and more are being developed. This article reviews existing navigational tools, including two developed at the Yale University School of Medicine, and points out their strengths and weaknesses. A major shortcoming of the present Internet navigation methods is the lack of controlled descriptions of the available resources. As a result, navigating the Internet is very difficult.

Using a network menu and the UMLS Information Sources Map to facilitate access to online reference materials.

As computer technology advances, clinicians and biomedical researchers are becoming more dependent upon information from online databases and information systems. By using specially configured computer workstations and high-speed computer networks, it is now possible to access this information in a rapid and straightforward manner. To empower users by providing these capabilities, the authors are assembling a variety of network workstations to be located throughout Yale-New Haven Medical Center. At the heart of the workstation is NetMenu, a program designed to help users connect to a number of important online information systems, including a hospital order entry and results reporting system, a drug reference, bibliographic retrieval systems, and educational programs. In addition, as part of the National Library of Medicine's Unified Medical Language System (UMLS) project, the authors have developed a local prototype of the UMLS Information Sources Map (ISM) and a companion query assistant program to complement the NetMenu in helping users select and connect automatically to information services relevant to a particular question. The ISM query assistant draws from a listing of many online information sources accessible via local and international networks.

NetMenu: experience in the implementation of an institutional menu of information sources.

NetMenu is a program, developed at Yale, which enables straightforward access to online information systems. NetMenu has been deployed in several diverse settings within our medical center. In the hospital, NetMenu is functioning as a front-end for our clinical workstation providing access to the hospital information system, the clinical laboratory computer, a drug database and several bibliographic databases. The medical libraries are utilizing NetMenu for both medical education workstations and for scholarly information workstations. This paper describes our initial experience in the implementation, support, and maintenance of NetMenu as an institutional menu of information sources.

Augmenting GRATEFUL MED with the UMLS Metathesaurus: an initial evaluation.

Clinicians in patient care settings must be able to locate relevant recent medical literature quickly. Computer literacy is increasing, but many clinicians remain ill at ease with search strategies for online bibliographic databases. As part of an ongoing project to simplify the translation of clinical questions into effective searches, a Unified Medical Language System (UMLS) Metathesaurus tool was designed. The authors compared bibliographic searches by relatively inexperienced users employing only GRATEFUL MED to searches done using GRATEFUL MED augmented with this tool. The users were clinicians examining questions related to a test set of clinical cases. Their problems and successes were monitored; the results suggest that the addition of a thesaurus helps resolve some problems in citation retrieval that trouble the novice user. By helping the user understand indexing terms in context and by reducing typing errors, a thesaurus can help provide an intelligent solution to lexical mismatches in bibliographic retrieval.

Teaching consultation psychiatry through computerized case simulation.

The PsyConsult Adventure Simulation program presents a case simulation of consultation in a general hospital. Exploring this computerized case helps trainees prepare for the complexities of consultation that they will face on the hospital wards. The simulation provides a distinctive approach, modeling the process of an actual consultation and allowing trainees to explore on their own initiative. It presents general techniques of psychiatric consultation as well as specifics of diagnosis and treatment. The program demonstrates the feasibility of using case simulation with a personal computer system as a supplement to bedside teaching of consultation psychiatry.

Automated online transition from the medical record to the psychiatric literature.

Psych Topix is a knowledge-based program which guides the clinician from an on-line clinical report to a search of the psychiatric literature or of other relevant databases. It provides this guidance by using an outline of key topics in a clinical field to provide "concept-based" links. Each topic is augmented with an activation expression to signal when that topic is potentially relevant to a case, and with database search expressions to allow focused retrieval of information. The bibliographic retrieval component of Psych Topix is currently operational as part of the daily, routine operation of a psychiatric consultation service. The system is also implemented in a demonstration mode to provide retrieval from three additional textual databases. The current Psych Topix system provides a working demonstration of the clinical feasibility of using concept-based links to facilitate the focused, automated transition between on-line medical databases.

Prototyping an institutional IAIMS/UMLS information environment for an academic medical center.

The paper describes a prototype information environment designed to link network-based information resources in an integrated fashion and thus enhance the information capabilities of an academic medical center. The prototype was implemented on a single Macintosh computer to permit exploration of the overall "information architecture" and to demonstrate the various desired capabilities prior to full-scale network-based implementation. At the heart of the prototype are two components: a diverse set of information resources available over an institutional computer network and an information sources map designed to assist users in finding and accessing information resources relevant to their needs. The paper describes these and other components of the prototype and presents a scenario illustrating its use. The prototype illustrates the link between the goals of two National Library of Medicine initiatives, the Integrated Academic Information Management System (IAIMS) and the Unified Medical Language System (UMLS).

From patient reports to bibliographic retrieval: a Meta-1 front-end.

A software front-end has been programmed to help construct Medline query expressions from selected text in clinical records. The user "clicks" to choose pertinent words or phrases from the text with a pointing device and the words are translated into Medical Subject Headings (MeSH). The National Library of Medicine's Unified Medical Language System Meta-1 Thesaurus is used to look up the words selected by the user. The software traces through chains of synonyms to assemble a small set of MeSH indexing terms. The user then makes the final selection from among the MeSH terms and combines chosen terms using logical connectives to form a Medline query which is passed on to Grateful Med. This approach provides the clinical user with a natural starting point, the text of a patient report with no need to know the MeSH terminology. The software handles the translation that otherwise would necessitate looking up terms in MeSH guidebooks, as well as handling the added drudgery of checking out different synonyms. Preliminary evaluation of this approach with clinical trainees indicated that they find the front-end a straightforward way to search for literature relevant to a clinical case. Having a tool for immediate translation from clinical terminology to indexing terminology seems to be an important factor. Apparently minor issues in interface design, such as keeping the clinical report displayed simultaneously along with the search under construction, and keeping both visible during the search itself seem to help orient the user.

Implementing a computer system for psychiatric training : the electric resident.

The Electric Resident System is an experimental arrangement of software for the personal computer. It is designed to help residents in the educational cycle of patient interview, literature review, write-up, attending review, and patient treatment. The authors emphasize the system's immediate utility and ease of operation, using a graphical interface. Within a year of operation this system was in daily use on a consultation service with minimal formal instruction. Usage data show a positive correlation between the number of patients seen per month and the number of computer-assisted MEDLINE literature searches performed. Residents' comments indicate not only acceptance of the system but increased interest in computer applications in medical care. The Electric Resident System is meant to be the first step toward a computer-aided residency.

Automated bibliographic retrieval based on current topics in hepatology: hepatopix.

The Hepatopix computer program helps the physician go from a computerized clinical record directly to a computerized search of the medical literature. The program uses a hierarchical list of current (key) topics in hepatology to offer "intelligent" searches. Each topic has associated "selection logic" and a tested Medline search. Starting with a liver biopsy case record, Hepatopix evaluates the selection logic to determine which topics may be pertinent to the case (based on clinical findings, lab tests, and critical words or phrases in the summary). The physician then picks those topics which are interesting enough to warrant a literature search. The citations are retrieved using search strategies stored for each topic and presented. Hepatopix is operational with over 200 topics in the realm of liver neoplasms, operating on liver biopsy case summaries from the Klatskin Database of Liver Biopsies. Besides demonstrating clinical case-directed bibliographic retrieval, it demonstrates the utility of a "key topics" list as a bridge between medical databases.

Capturing the semantic relationship between clinical terms with current MeSH bibliographic coding.

This paper compares bibliographic retrieval using current MeSH (Medical Subject Headings) to bibliographic retrieval using explicitly coded semantic relationships between index terms. In a previous study, ten lists of abstracts, each list containing 20-40 papers discussing a specific pair of terms, were analyzed to identify the specific relationship(s) between those terms discussed in each paper. In the present study, we analyze how well current MeSH coding using topical subheadings and check tags, can selectively retrieve those papers discussing each semantic relationship.

Semantically assisted medical bibliographic retrieval: an experimental computer system.

An experimental computer-based bibliographic retrieval system has been implemented to explore how semantic (conceptual) relationships between MeSH terms might assist the retrieval process. To construct the experimental system's database, lists of abstracts were produced using MEDLINE. Each list contained papers discussing a specified pair of terms. Each abstract was then analyzed to determine the specific relationship(s) between the two terms discussed in that paper. The project then explored how these semantic relationships could be incorporated into the computer to enhance bibliographic retrieval.