Outcomes research using the electronic patient record: Beth Israel Hospital's experience with anticoagulation.

Using data captured as part of the routine care of outpatients taking the oral anticoagulant warfarin, we described variation in recording reasons for anticoagulation, selecting target International Normalized Ratio (INR) ranges, and performing coagulation blood tests. Laboratory results were directly captured by or entered into an Anticoagulation Flowsheet, a computer program which is fully integrated with our Online Medical Record (OMR). We studied the 177 patients with flowsheets between October 1993 and January 1995. 90% had a reason for anticoagulation entered; 29 different target INR ranges were entered. For patients with a target INR of 2.0-3.0, the mean number of weeks between blood tests, after a test which was in range, was three weeks (standard deviation 1.7 weeks, range one to twelve weeks). We conclude that routinely collected data contained in an electronic patient record (EPR) can be a rich resource for describing and evaluating clinical practice. We also address several limitations to using EPR data: validity of EPR information, lack of coded information, and imperfect capture of clinician thought processes.

A clinical trial of a knowledge-based medical record.

To meet the needs of primary care physicians caring for patients with HIV infection, we developed a knowledge-based medical record to allow the on-line patient record to play an active role in the care process. These programs integrate the on-line patient record, rule-based decision support, and full-text information retrieval into a clinical workstation for the practicing clinician. To determine whether use of a knowledge-based medical record was associated with more rapid and complete adherence to practice guidelines and improved quality of care, we performed a controlled clinical trial among physicians and nurse practitioners caring for 349 patients infected with the human immuno-deficiency virus (HIV); 191 patients were treated by 65 physicians and nurse practitioners assigned to the intervention group, and 158 patients were treated by 61 physicians and nurse practitioners assigned to the control group. During the 18-month study period, the computer generated 303 alerts in the intervention group and 388 in the control group. The median response time of clinicians to these alerts was 11 days in the intervention group and 52 days in the control group (PJJ0.0001, log-rank test). During the study, the computer generated 432 primary care reminders for the intervention group and 360 reminders for the control group. The median response time of clinicians to these alerts was 114 days in the intervention group and more than 500 days in the control group (PJJ0.0001, log-rank test). Of the 191 patients in the intervention group, 67 (35%) had one or more hospitalizations, compared with 70 (44%) of the 158 patients in the control group (PJ=J0.04, Wilcoxon test stratified for initial CD4 count). There was no difference in survival between the intervention and control groups (P = 0.18, log-rank test). We conclude that our clinical workstation significantly changed physicians' behavior in terms of their response to alerts regarding primary care interventions and that these interventions have led to fewer patients with HIV infection being admitted to the hospital.

A computer-based outpatient medical record for a teaching hospital.

We developed a computer-based outpatient medical record system to facilitate direct physician interaction with the clinical computing system at the Beth Israel Hospital in Boston. During the 2 years since the medical record system was installed, 20 staff physicians, 5 fellows, 64 residents, and 11 nurse practitioners have entered 15,121 active problems and 1996 inactive problems for 3524 patients, as well as 12,651 active medications and 1894 discontinued medications for 3430 patients. Another 20,321 items were entered on health-promotion and disease-prevention screening sheets, and with the help of automatic updating by the computer, an additional 21,897 entries on screening sheets were made for 8686 patients. Clinicians wrote 10.9 +/- 12.8 (mean +/- SD) words per problem when they were working at the computer, as compared with 4.3 +/- 2.5 words per problem when they were writing in the paper medical record. We conclude that physicians will readily enter data directly into a computing system when they are given appropriate tools, and that they consider the computer-based problem list to be a valuable improvement over its paper counterpart. Use of a computer-based medical record system has obvious benefits for data management and patient care.

Outpatient medical records for a teaching hospital: beginning the physician-computer dialogue.

We have developed an outpatient medical record (OMR) system designed to facilitate direct physician interaction with the computer-based medical record. During the first two years the system was in use, staff physicians, residents, and nurse practitioners entered 15,121 active and 1996 inactive problems for 3524 patients, and 12,651 active medications and 1894 discontinued medications for 3430 patients. These clinicians entered 20,321 items on health promotion and disease prevention screening sheets and with the help of automatic updating by the computer an additional 21,897 entries on screening sheets were made for 8686 patients. On the computer, clinicians wrote more than twice as much--10.9 words per problem, in contrast to 4.3 words per problem in the paper record (p less than 0.0001, Student's t). We conclude that clinicians perceived the computer-based problem list to be more valuable than its paper counterpart.

ClinQuery: searching a large clinical database.

We designed a user-friendly computer program that permits physicians to use clinical and demographic descriptors to search a hospital's clinical database for purposes of patient care, teaching, and research. For example, the user can identify all admissions in which diabetic ketoacidosis was diagnosed, the serum bicarbonate level was under 12 mmol/liter, and the length of stay exceeded 7 days. Once particular admissions have been identified, all data stored in the computerized record can be displayed. Authorized persons can also request the patient's complete medical record for further study. Over a 5-year period, 895 doctors, nurses, medical students, and hospital administrators used Clin-Query to search the clinical database of Boston's Beth Israel Hospital 3724 times. They displayed detailed information on 72,489 patients and requested the complete medical record 5477 times. Responses to a computer-based questionnaire indicated that 16% of the searches were performed for patient care, 38% for clinical research, 16% for teaching and education, 12% for hospital administration, and 18% for general exploration. We conclude that physicians and allied personnel will repeatedly examine and analyze aggregate clinical information when they are provided with the appropriate tools.

ClinQuery: a system for online searching of data in a teaching hospital.

We designed a user-friendly computer program that permits physicians to search the clinical database of Boston's Beth Israel Hospital by clinical and demographic descriptors. For example, the user can identify all admissions in which diabetic ketoacidosis was diagnosed, the serum bicarbonate level was under 12 mmol/L, and the length of stay exceeded 7 days. Once particular admissions are identified, all data stored in the computerized record can be displayed. Authorized persons can also request the patient's complete medical record for further study. Over a 30-month period, 530 doctors, nurses, medical students, and administrators used the program to search the hospital's clinical database 1786 times. They displayed detailed information on 30,851 patients and requested the complete medical record 5319 times. In 1389 of the 1786 searches completed, the searcher responded to a computer-based questionnaire about motivation for the search. Responses indicated that 32% of the searches were for clinical research, 17% for patient care, 17% for teaching and education, 11% for hospital administration, and 12% for general exploration. In 58% of the searches, respondents indicated definite or probable success in finding the desired information. We conclude that physicians and allied personnel will repeatedly obtain, view, and analyze aggregate clinical information if they are provided with appropriate tools. We believe that such access to clinical information is an important resource for patient care, teaching, and clinical research.