Is telemedicine justifiable?

A three-year experience in urban telemedicine is presented. The digital technology linking a community teaching hospital to a nearby clinic is described, as is the typical protocol for the consultations. The medical advantages and disadvantages, the security implications, and the cost-effectiveness of this project are analyzed.

HOLON: a Web-based framework for fostering guideline applications.

HOLON is a research and development effort in extending middleware in the healthcare field to support application development, in general, and guideline applications, in particular. This framework makes use of open standards for architecture, software, guideline KBs, clinical repository models, information encodings, and intelligent system modules and agents. By pursuing the use of such standards in our middleware components, we hope eventually to maximize reusability of the HOLON framework by others who also adhere to these open standards. This research reflects lessons learned about the extensions needed in these standards if healthcare middleware frameworks are to transparently support application developers and their users over the web.

Informatics integration in a medical residency program: early experiences.

In 1992, Informatics training was integrated into the medical residency program at Norwalk Hospital. The program objective was to familiarize the residents with clinical applications of information technology that could enhance their productivity in clinical practice. In its first year, the curriculum was theory oriented. Evaluation of the program at the end of the first year led to a significant restructuring of the program format and curriculum. The trainees did not find theory to be of immediate clinical value, in the second year the program emphasis was redirected toward the development of practical skills. Next year, in 1993, 'Informatics Clinics' were initiated to develop practical Informatics skills that would be useful in a clinical setting. This approach was more successful but did not offer a complete solution. The degree to which the concepts and methods learned are clinically utilized by residents will depend upon the degree of reinforcement provided in the clinical residency years. In addition, there is a need for the development of assessment standards for the evaluation of Informatics literacy levels. In the absence of assessment standards the level of Informatics literacy in medical graduates remains undetermined Consequently, it is difficult to determine whether the training received has transformed expectations into reality.

Primary health care computing analysis of Swedish maternal health records.

In our attempt to develop an "Essential Data Set" for a computer based information system to support Maternal & Child Health Care services an analysis of Swedish maternal care services was undertaken. The present study analyses the information system in the domain of maternal and child health care at the primary health center level with a view to identify areas where a computer-based medical record could effect improvements. The study showed that even in a well organized maternal care service as in Sweden lacunae exist in the information system. The paper forms, called MHV1, MHV2, MHV3 and FV1, though well designed, were incomplete in a large number of the cases. The MHV1 forms were completed in less than 45%, the MHV 2 form in 87.5% and the FV1 form in 70% of the cases. Certain elements of the data set were less likely to be completed than others. Another weak spot was the inaccessibility of the paper records during off-hours. These deficiencies could be eliminated by the use of a computerized medical record based on an essential data set.

Education review: applied medical informatics--informatics in medical education.

The importance of informatics training within a health sciences program is well recognized and is being implemented on an increasing scale. At Chicago Medical School (CMS), the Informatics program incorporates information technology at every stage of medical education. First-year students are offered an elective in computer topics that concentrate on basic computer literacy. Second-year students learn information management such as entry and information retrieval skills. For example, during the Introduction to Clinical Medicine course, the student is exposed to the Intelligent Medical Record-Entry (IMR-E), allowing the student to enter and organize information gathered from patient encounters. In the third year, students in the Internal Medicine rotation at Norwalk Hospital use Macintosh power books to enter and manage their patients. Patient data gathered by the student are stored in a local server in Norwalk Hospital. In the final year, we teach students the role of informatics in clinical decision making. The present senior class at CMS has been exposed to the power of medical informatics tools for several years. The use of these informatics tools at the point of care is stressed.

Computer-based patient record: the essential data set approach.

The clamor for data to study the impact of care, to evaluate clinical performance and justify resource utilization is increasing. The data in demand normally should exist in the record of a clinical encounter. Advances in information technology and software techniques have provided us with tools to develop and implement computer-based patient record systems. The issues that constrain development are integral issues of clinical medicine, such as the variability in medical data, specialized practice of medicine, and differing demands of the numerous end-users of a medical record. This paper describes an approach to develop a computer-based patient record. The focus is on identification of the essential data set by infological data modeling and its implementation in a commercially available package for a physician's office.

MCHS: an application software for family welfare programmes.

At the level of first contact, a primary health care centre, information management is an unwieldy task, therefore health information systems are reported to be inadequate and weak. Microcomputers could improve information management at this level, but there is little success due to a lack of specialized application software. In this paper we describe software developed after a multi-centre systems analysis study, on an essential data set, to support the delivery of the public health programmes for family welfare, i.e. maternal health care, family planning and immunization programmes. The modular approach was taken to develop a common application software for information management use at multiple sites. The software is tested in a laboratory mode by retrospective data entry from sites in Sweden and in India. All the information could be entered and site-specific reports that were generated are compared. The software provided a common data collection format, an essential platform for outcomes research.

Application of an essential data set based computer system in support of maternal and child care.

A simple functional application software has been developed to support care providers in information management related to perinatal care activities, family planning encounters and the immunization of infants. This was distributed to some sites and was implemented with no organizational change, though the methods differed. An early assessment of the software after a period of implementation is made based on the observations and experiences reported. This is presented in a framework outlined earlier as the OUST model. The systems objective to enhance the value of information was observed to have been partially achieved. The utility to the users is observed in the ability of the end-users at the sites to identify the local community needs and adopt accordingly suitable strategies. The social impact was seen in the assistance provided by the sentinel action of the system in tracking dropouts from the immunization programme at a site, thereby ensuring quality in care and also economic benefits. From a technical standpoint, the application software was small yet functional and in it were incorporated features that ensured data quality. The application software was designed to generate a unique identity code to assist in follow-up of the target population. Based on the data entered it compiled reports to meet administrative requirements, reports that gave the care providers feedback and lists to coordinate in the follow-up of the target population. The application software is a common data collection tool that can assist in building a data registry for health outcomes research.

Towards an essential data set: applicability in the domain of maternal health services.

There is a need for consensus on the quantity of data that must be available in a computer-based information system of a health care organization. In this paper we take up the issue of defining the data content of an information system and introduce the concept of Essential Data Sets with an explicit methodology which was applied to define a data set for the Maternal Health Services program. A key step in the method was a recognized technique used in systems development process called data modelling, in this case infological modelling, by an interdisciplinary group. A preliminary set of 86 data elements was identified and it provided the foundation for development of an application software for discussion and a real-world testing framework. The acceptability of the data set was tested in a laboratory perspective by retrospective data entry from records of 94 pregnant women registered at a maternal health care center in Sweden. Data from a total of 1,318 prenatal visits, an outcome visit, and a postnatal visit for each woman was entered into a computer using the software, with no loss of information. Thus, in a short-term perspective the acceptability of the data set was demonstrated. The software has since been implemented for pilot prospective studies at sites in India and Sweden. The use of a common data protocol is an essential foundation for patient outcome research, especially as the trend of health care management has changed from a "process of care" orientation to an "outcome of care" orientation.

Impact on the management and delivery of primary health care by a computer-based information system.

Timely and accurate information forms the basis for management to plan and for care providers to take appropriate action. We report from a developing country a research project aimed to strengthen the information infrastructure with a computer at a Primary Health Centre. The software (MCHS) was designed to assist the care providers in the information management for the Maternal and Child Health (MCH) programme activities. In Phase I, a baseline survey was conducted to identify the needs and target groups. In Phase II, the MCHS was integrated into routine delivery of MCH to monitor the target population and help in evaluation. The research project's impact is reflected in enhanced utilization of services and quality in care, as seen by reduction of dropouts from the immunization program. In economic terms, we see that the costs for a fully immunised child are reduced with reduction of dropouts; thus, the computer system contributes to quality assurance and cost effectiveness in delivery of care.

Multi centre systems analysis study of primary health care: a study of socio-organizational and human factors.

The information management systems to support health programmes are inadequate. As computers become cheaper and more powerful, their application in the strengthening of the information infrastructure becomes more feasible. However, the high cost of specialized applications software limits their potential, especially in developing countries. A multi-centre systems analysis, (a descriptive study using a questionnaire), was made of District Health Sites in developing countries to analyse whether a common specialized application software design for implementation at a primary health care centre was feasible. Responses to the questionnaires by physicians at the primary health centres were compared between district health sites using contingency tables. Significant inter-site differences in social factors existed, respondents had no prior experience, but with near unanimity (98%) accepted the idea of computer assistance in their work. However, general reservations (31%) and fears (26%) about computer interference in the doctor-patient relationship were expressed. The human factor must be considered in interface design and training before implementation.

A multicenter study of data collection and communication at primary health care centers.

Health care delivery is information intensive. As computer applications make information available to the decision maker with speed and accuracy, informatics applications will strengthen the infrastructure. This paper is the second part of a multicenter systems analysis study to design a common application software to support primary health care focused on information flow. We present the questionnaire analysis and observations from a field study of a district health site. Analyses using contingency tables revealed differences, some statistically significant. The field study confirmed that minor differences exist even within a district health site. Development of a common application software on the basis of information flow studies is feasible. However, to make optimum use of computer implementation, revision of the health information systems was recommended. It was suggested that application software be developed with the core data set required by the care providers to deliver and administrators to manage a vertical health program.

Computer based information systems in primary health care--why?

The delivery of health care is information based. A host of computer-based information systems have been developed and implemented in the health care environment. The mere availability of the computer as a tool for information handling should, in itself, not be the cause for developing computer-based information systems. The earlier assumption of a cost-benefit impact with the development of such systems has not been effectively shown in all cases, and as seen in a report by van Bemmel, the recent trend is to apply other criteria in systems evaluation. Information is essential in health care related decision making. The properties of information are described to present a case for a computer-based information system to support primary health care delivery.

Computers and physicians--an appraisal study.

The use of computers to improve health care delivery in a cost-conscious era is increasingly considered appropriate and is even recommended by the World Health Organization. Provision of adequate and appropriate health care requires a large amount of information. However, the assessment of acceptance, of existing skills and of the ability of people to learn and absorb computer technology is still a neglected aspect in the implementation of computer systems. Therefore, in order to address this problem, a study was performed among end users in a rapidly developing country. The results demonstrated that the physicians are interested, but that an information gap exists. Respondents with some experience and information accepted the potential of the computer as a decision support tool, but those without experience had reservations.