A web-based rapid prototyping and clinical conversational system that complements electronic patient record system.

Even the most extensive hospital information system cannot support all the complex and ever-changing demands associated with a clinical database, such as providing department or personal data forms, and rating scales. Well-designed clinical dialogue programs may facilitate direct interaction of patients with their medical records. Incorporation of extensive and loosely structured clinical data into an existing medical record system is an essential step towards a comprehensive clinical information system, and can best be achieved when the practitioner and the patient directly enter the contents. We have developed a rapid prototyping and clinical conversational system that complements the electronic medical record system, with its generic data structure and standard communication interfaces based on Web technology. We believe our approach can enhance collaboration between consumer-oriented and provider-oriented information systems.

Patient-Computer Dialogue: A Review.

Since the first study of communication between patient and computer was performed at the University of Wisconsin in 1965, programs for patient-computer dialogue have been developed, implemented, and studied in numerous settings in the United States and abroad, and the results have been encouraging. This review presents a brief history of patient-computer dialogue together with suggested guidelines for programs in the future.

The CCC system in two teaching hospitals: a progress report.

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

Psychological predictors of subsequent medical care among patients hospitalized with cardiac disease.

BACKGROUND: There have been numerous reports indicating a relation between psychological distress and coronary artery disease. The authors tried to determine whether psychological distress in patients hospitalized for coronary artery disease is associated with the amount of medical care required after discharge. METHODS: Using a prospective clinical cohort, 210 patients who had been admitted for myocardial infarction (n = 67), percutaneous transluminal coronary angioplasty (n = 75), or coronary artery bypass grafting (n = 68) were followed for 6 months. Index psychological status was determined from questionnaires measuring depression and anxiety. Disease severity was assessed by the index hospitalization medical record of left ventricular ejection fraction, number of stenotic vessels, and number of noncardiac comorbidities. The amount of subsequent medical care delivered was based on the number of days of rehospitalization for cardiac-related illness and for any reason within 6 months after discharge. This was determined from a combination of computer medical record and patient self-report. RESULTS: The authors first determined that both psychological depression and disease severity each predicted days of rehospitalization. (Anxiety was not predictive of rehospitalization.) Next, disease severity was controlled for using partial correlation, and depression was still predictive of rehospitalization. Finally, the authors combined the predictor variables using a regression model to predict rehospitalization. Depression was a significant main effect in all models predicting rehospitalization. CONCLUSIONS: Psychological depression appears to be an important predictor of rehospitalization among persons who have been admitted with coronary artery disease.

Development of a knowledge-based electronic patient record.

To help clinicians care for patients with HIV infection, we developed an interactive knowledge-based electronic patient record that integrates rule-based decision support and full-text information retrieval with an online patient record. This highly interactive clinical workstation now allows the clinicians at a large primary care practice (30,000 ambulatory visits per year) to use online information resources and fully electronic patient records during all patient encounters. The resulting practice database is continually updated with outcome data on a cohort of 700 patients with HIV infection. As a byproduct of this integrated system, we have developed improved statistical methods to measure the effects of electronic alerts and reminders.

Measurement of intelligence: misplaced trust and the lure of prophecy.

A careful look at studies of "intelligence" and "aptitude" tests belies the contention that these tests measure heritable attributes. Rather, they are achievement tests that measure learned abilities. When stripped of the aura of "intelligence" and "aptitude" and compared with other indexes of accomplishment, they are poor predictors of future performance. Furthermore, when promulgated as measures of cognitive potential, they are socially harmful, particularly to disadvantaged children.

Guidelines for management of HIV infection with computer-based patient's record.

Computers are steadily being incorporated in clinical practice. We conducted a nonrandomised, controlled, prospective trial of electronic messages designed to enhance adherence to clinical practice guidelines. We studied 126 physicians and nurse practitioners who used electronic medical records when caring for 349 patients with HIV infection in a primary care practice. We analysed the response times of clinicians to the situations that triggered alerts and reminders, the number of ambulatory visits, and hospitalisation. The median response times to 303 alerts in the intervention group and 388 alerts in the control group were 11 and 52 days (p < 0.0001), respectively. The median response time to 432 reminders in the intervention group was 114 days and that for 360 reminders in the control group was over 500 days (p < 0.0001). There was no effect on visits to the primary care practice. There was, however, a significant increase in the rate of visits outside the primary care practice (p = 0.02), which is explained by the increased frequency of visits to ophthalmologists. There were no differences in admission rates (p = 0.47), in admissions for pneumocystosis (p = 0.09), in visits to the emergency ward (p = 0.24), or in survival (p = 0.19). We conclude that the electronic medical record was effective in helping clinicians adhere to practice guidelines.

Protection of confidentiality in the computer-based patient record.

To evaluate the confidentiality of the patients' data in the electronic patient records designed by members of the Center for Clinical Computing in Boston, we examined the accessibility of the computer-stored medical records of two groups of patients at Boston's Beth Israel Hospital: celebrities, hospital employees, and their relatives (VIPs) and other patients (non-VIPs). We studied how often authorized clinicians gained access to computer-stored data on the two types of patients and whether look-up patterns differed if the data concerned a VIP. Our results suggest that the measures used to maintain data confidentiality at Beth Israel Hospital are adequate.

A computer-administered health screening interview for hospital personnel.

We developed a computer-administered health screening interview for the employees of an urban teaching hospital. The interview is part of the integrated Center for Clinical Computing (CCC) clinical information system used throughout the hospital, and is available on any of 2000 terminals. Conducted in private and with protection of confidentiality, the interview seeks information on medical problems and patterns of living for which behavioral change is considered desirable. In a four-year period ending in May 1994, 1937 employees completed the interview. The results showed that stress and unhappiness were common: 57% of the employees reported high levels of stress, and 42% reported feeling sad, discouraged, or hopeless in the previous month; 6% indicated that life sometimes did not seem worth living. Eighty-six percent of the employees expressed an interest in the health-related programs offered by the hospital: 72% were interested in the fitness center, and 37% in the stress-reduction program. We conclude that if interactive health-promotion programs are easily available, they will be used and appreciated in the work place. The programs can be written to reveal the employees' health concerns and stimulate their interest in promoting their own health.

Patient entries in the electronic medical record: an interactive interview used in primary care.

We describe the development, implementation, and use of a computer-administered patient interview, the Health History Interview, by over 300 new patients in a primary care practice at Boston's Beth Israel Hospital. The interview has been well accepted by patients and rated positively by providers. It electronically captures clinical information directly from patients for use during their initial encounter with a provider. It facilitates aggregate analysis of clinical data for quality improvement efforts, such as aiming preventive medicine interventions at identified problem areas within the clinic. Expectations management has been an important task throughout the project. Increasing use of the interview beyond the 30-40% of new patients who have taken it will require greater communication with patients, greater convenience to patients and providers, and more evidence of the clinical, administrative, and research benefits of the technique. Most important, full implementation will require fundamental changes in physician practice habits and patterns of communication between patients and the health care system, as well as clearly demonstrated cost-benefit improvements through the use of these tools.