Computer-based Patient Record Research Articles

Progress and Promise of Diabetes Research

THE EPIDEMIC OF DIABETES HAS TAKEN HOLD AND IS EXtending to new populations. The prevalence of type 2 diabetes in children and in developing nations has increased dramatically, and adult-onset type 1 diabetes is now well recognized. Diabetic cardiovascular disease has become a worldwide burden. While new cases of heart disease and cancer are stable or decreasing, the incidence of diabetes has increased 6% annually in the United States and more than that in developing countries. The human and economic toll of diabetes increases correspondingly, and this requires an integrated, global response. However, policy makers, insurance companies, and the general public are just beginning to recognize the seriousness of diabetes. Opportunities for progress are virtually limitless, with some of the most fundamental questions raised by diabetes remaining unanswered: What underlies the metabolic syndrome? What exactly mediates the link between obesity and insulin resistance? Can this resistance be overcome pharmacologically? What triggers the process that destroys beta cells in type 1 diabetes? How can that process be prevented? Can the enormous potential of cell therapy and mechanical insulin delivery be realized? How can individuals with diabetes be motivated to follow self-care patterns necessary to prevent complications? How can an entire society be motivated to decrease its food consumption? How can prevention be paid for while reducing the total cost of diabetes care? The articles in this theme issue of THE JOURNAL address important questions in diabetes today, and also illustrate some of the newer methods being applied to diabetes research. Just as new techniques undergird the advances in basic science, so they also enhance clinical research. This issue includes reports from a large community observational cohort study, linked state and hospital databases, a computerbased patient record review, a cost-effectiveness analysis, 2 randomized controlled trials, and long-term follow-up of an important clinical study. There is keen interest in the events that precede diabetes, and researchers are seeking to discover diabetogenic genes. The thrifty gene hypothesis postulates that some individuals store fat more efficiently, adapting well to periods of starvation, but poorly to times of plenty. This concept is undoubtedly oversimplified—type 2 diabetes is polygenic. Moreover, it is possible that the multiple genes may express themselves through such nontraditional phenotypes as susceptibility to obesity from dysregulation of appetite. A related area of interest is the “minienvironment of the uterus,” and the role that early imprinting can have on later life. The study by Innes and colleagues examines whether a woman’s birth weight influences her risk of developing gestational diabetes, which is a marker for risk of type 2 diabetes. Linking hospital discharge data to state vital records, the authors report that women with lower birth weights as newborns were more likely to develop gestational diabetes. This finding is consistent with results obtained under extremely different circumstances— pregnant women in the Netherlands during a fixed period of Nazi-imposed famine during World War II gave birth to offspring that were predisposed to type 2 diabetes. In a longitudinal community observational study, Wong and colleagues made the surprising observation of an association between retinal arteriolar narrowing and the risk of incident diabetes. The implication is that diabetes not only causes, but may be caused by, microvascular disease. These results call to mind the work of Siperstein and colleagues in the 1960s and 1970s, which suggested capillary basement membrane thickening precedes the onset of diabetes. Studies of patients prior to the diagnosis of diabetes raise the potential for primary prevention, while improved management of diabetes could prevent complications. Davies and colleagues studied what might be considered an unlikely insulin sensitizer—alcohol. In a randomized, controlled, crossover study of healthy postmenopausal women, the authors found improved insulin sensitivity

Patients' and physicians' understanding of health and biomedical concepts: relationship to the design of EMR systems

Objective: The aim of this paper is to examine knowledge organization and reasoning strategies involved in physician–patient communication and to consider how these are affected by the use of computer tools, in particular, electronic medical record (EMR) systems. Design: In the first part of the paper, we summarize results from a study in which patients were interviewed before their interactions with physicians and where physician–patient interactions were recorded and analyzed to evaluate patients' and physicians' understanding of the patient problem. We give a detailed presentation of one of such interaction, with characterizations of physician and patient models. In a second set of studies, the contents of both paper and EMRs were compared and in addition, physician–patient interactions (involving the use of EMR technology) were video recorded and analyzed to assess physicians' information gathering and knowledge organization for medical decision-making. Results: Physicians explained the patient problems in terms of causal pathophysiological knowledge underlying the disease (disease model), whereas patients explained them in terms of narrative structures of illness (illness model). The data-driven nature of the traditional physician–patient interaction allows physicians to capture the temporal flow of events and to document key aspects of the patients' narratives. Use of electronic medical records was found to influence the way patient data were gathered, resulting in information loss and disruption of temporal sequence of events in assessing patient problem. Conclusions: The physician–patient interview allows physicians to capture crucial aspects of the patient's illness model, which are necessary for understanding the problem from the patients' perspective. Use of computer-based patient record technology may lead to a loss of this relevant information. As a consequence, designers of such systems should take into account information relevant to the patient comprehension of medical problems, which will influence their compliance.

A randomized, controlled trial of clinical information shared from another institution

Study Objective: Emergency physicians often must deliver medical care with minimal access to historical clinical information. We demonstrate the feasibility and potential value of increased access to patients’ clinical information from another hospital while they are receiving care in the emergency department. Methods: We conducted a pilot randomized, controlled trial of providing information from a large, longitudinal, computer-based patient record system of clinical data from an urban hospital to emergency physicians at either of 2 urban EDs. We randomized patients seen at either ED to have the information from the computer-based patient record system provided to their physician or to not have the information provided. We delivered information to the emergency physician both as a printed abstract and by means of online access to the computer-based patient record. We assessed charges, hospital admissions, repeat visits to EDs, and the emergency physicians’ satisfaction with the information. Results: Under certain assumptions, the intervention was estimated to decrease charges for ED care by approximately $26 per encounter (P =.03) at 1 hospital, but there was no effect on charges at the other hospital. This result was likely because of marked differences in the workflows and information access at these 2 EDs. We demonstrated no differences in admission rates or repeat visits to the ED. Emergency physicians identified that remembering their passwords and the time required to search for the information were significant barriers to accessing clinical information online. Conclusion: Our pilot study is the first to demonstrate the feasibility of sharing clinical information between different health care systems. We observed a trend toward cost savings at 1 of 2 hospitals and no differences in the quality measures we studied. Our experience underscores the difficulties inherent in studying the effects of community-wide health care interventions on cost and quality of ED care. [Overhage JM, Dexter PR, Perkins SM, Cordell WH, McGoff J, McGrath R, McDonald CJ. A randomized, controlled trial of clinical information shared from another institution. Ann Emerg Med. January 2002;39:14-23.]

Medicine in the 21st Century: Global Problems, Global Solutions

To discuss application areas of information technology in medicine and health care on the occasion of the opening of the Private Universität für Medizinische Informatik und Technik Tirol/University for Health Informatics and Technology Tyrol (UMIT) at Innsbruck, Tyrol, Austria. Important application areas of information technology in medicine and health are appropriate individual access to medical knowledge, new engineering developments such as new radiant imaging methods and the implantable pacemaker/defibrillator devices, mathematical modeling for understanding the workings of the human body, the computer-based patient record, as well as new knowledge in molecular biology, human genetics, and biotechnology. Challenges and responsibilities for medical informatics research include medical data privacy and intellectual property rights inherent in the content of the information systems.

Computer-based Patient Record System and Pediatric Surgery

Computer-based Patient Record System and Pediatric Surgery

The Electronic Oral Health Record

This paper presents the history of the use of the computer for maintaining patient medical care information. An electronic record generated with a computer, which is non-specific for any healthcare specialty, is referred to as the electronic health record. The electronic health record was previously called the computer-based patient record. "Electronic" replaced the earlier term "computer-based" because "electronic" better describes the medium in which the patient record is managed. The electronic health record and its application to dentistry are discussed. The electronic health record is a "database" of patient information that has been entered by any healthcare provider; the electronic oral health record is an "electronic record" of oral health information that has been entered by an oral healthcare provider. The significant differences between the electronic health record and the electronic oral health record are outlined and highlighted. Included is a template describing a procedure to be used by dental personnel during the decision making process of purchasing an electronic oral health record. A brief description of a practice template is also provided. These completed templates can be shared with dental software vendors to clarify their understanding of and to clearly describe the needs of today's dental practice. The challenge of introducing information technology into educational institutions' curricula is identified. Finally, the potential benefit of using electronic technology for managing oral healthcare information is outlined.

Computer-based Patient Records

Computer-based Patient Records

Section 2: Computer-based Patient Records

Section 2: Computer-based Patient Records

Activity patterns in health care

Concerning the development and adoption of the computer-based patient record (CPR), an unsolved problem is still the approach that should be taken to construct a highly configurable, generic CPR. The first step in finding such an approach, is the identification of generic activity patterns. These are considered to be helpful in the identification of components. We identified twelve generic activity patterns in the interaction between a patient and a care-cluster.

How the past teaches the future: ACMI distinguished lecture.

More than 30 years of experience in developing a computer-based patient record system, The Medical Record (TMR), in multiple settings, in multiple specialty groups, and at multiple sites has taught us many lessons. Lessons related to computer-based patient records include the importance of a data model in which input, storage, and planned use are independent; separation of patient-specific data from metadata; a modular design to localize the program code that deals with a set of data; redundant storage to optimize tasks and response time; and integration of decision support into work process. Lessons related to medical informatics include the importance of a clinical-technical partnership, control of tools at the leading edge, and rapid prototyping in the real world. Finally, changes in technology move the challenges but do not eliminate them.

Patient satisfaction with telemedicine in home health services for the elderly

In a pilot study of telemedicine in home health services (HHS) for elderly patients, we implemented and evaluated a telemedicine system with a 33-kbs narrow-band approach to determine its effectiveness in providing quality services. Fifty patients were selected for the study. We found that telemedicine was effective in terms of reducing the number of clinic visits and achieving patient satisfaction. The average number of clinic visits per month was significantly decreased from 0.64 to 0.42 (p<0.05) after the use of telemedicine. 72% of patients were satisfied with telemedicine, but only patient location showed a significant difference for patient satisfaction (p<0.05). Patients in their homes (82%) were more satisfied than patients in nursing homes (50%). Of four types of services provided, medical consultation (100%) was the most highly satisfactory service with telemedicine, followed by physical therapy (83.3%). Although the satisfaction scores did not indicate a significant difference in the system characteristics, the quality of verbal communication appeared to be a more important factor in influencing patient satisfaction than set-up time or quality of image. A computer-based patient record was also developed to view a patient summary and to document encounters at the patient's home. Since the system is a low-cost approach that is easy to interface with a notebook computer, it can support various other HHSs.

A tecnologia da informação na área hospitalar: um caso de implementação de um sistema de registro de pacientes

O sistema de registro médico computadorizado, ou seja, o desenvolvimento do prontuário eletrônico, é um dos temas mais discutidos nos dias de hoje na área de informática médica. Há afirmações de que a combinação de computadores, redes de telecomunicações, informações médicas e dados eletrônicos de pacientes pode melhorar a qualidade do cuidado de saúde, a produtividade dos profissionais de saúde, facilitar o acesso aos serviços disponíveis e reduzir custos administrativos associados à prestação de serviços. O registro de pacientes é considerado o módulo básico de um sistema computadorizado de gerenciamento de pacientes e, conseqüentemente, do prontuário eletrônico. Uma tentativa é feita, neste trabalho, para descrever a implementação de um sistema de registro de pacientes, denominado R-ATA (registro-admissão, transferência e alta), no Hospital Universitário Lauro Wanderley da Universidade Federal da Paraíba.

History and trends in clinical information systems in the United States.

To provide a synopsis of issues about clinical information systems for nurses not schooled in nursing informatics. The past, present, and future of clinical computing, including major factors resulting in the early hospital information systems (HIS) and decision support systems (DSS) in the United States, current advances and issues in managing clinical information, and future trends and issues. Literature review and analysis. The first HIS and DSS were used in the late 1960s and were focused on applications for acute care. The change from fee-for-service to managed care required a change in the design of clinical information systems toward more patient-centered systems that span the care continuum, such as the computer-based patient record (CPR). Current difficulties with CPR systems include lack of systems integration, data standardization, and implementation. Increased advances in information and technology integration and increased use of the Internet for health information will shape the future of clinical information systems.

Computer-based patient record systems.

To provide oncology nurses with an overview of computer-based patient record (CPR) systems, a key infrastructure requirement in information management that is essential to maintaining a scientific basis for health care. Published articles, research studies, and review articles pertaining to CPR systems. Progress in hardware development, software applications, and interfaces combine to bring us multimedia patient record systems. Many obstacles have been overcome as standards have emerged and technologies conform to those standards. However, there has been limited success in implementation of such systems. Early acceptance of structured data and problem-oriented documentation set the framework for charting in the electronic record. Oncology clinicians and cancer patients alike will realize greater efficiencies and increased quality in health care when the CPR is fully implemented.

Health informatics and oncology nursing.

To provide an overview of the essential role of health and nursing informatics in meeting the 21st century call to provide state-of-the-art oncology care. Published articles, research studies, and documents relating to informatics. Health and nursing informatics encompass the pivotal roles of data and information; identifying and documenting essential data using nursing vocabularies; ensuring adequate computer-based patient record systems; accessing and building knowledge; using telecommunications to support care delivery; empowering the consumer through health informatics; transforming education; and enhancing decision making in oncology nursing through national research agendas. The information age calls us to explore digital and information technologies as extensions of human capacity. Oncology nursing practice is especially positioned to contribute to the health of our population.

Defining team processes using OO metaphors

In 1996,the Office of the US Assistant Secretary of Defense (Health Affairs), Clinical Business Area, began investigating the use of object oriented technology for its Computer-Based Patient Record program. It commissioned the CIOOT project (CPR Interoperability Using Object-Oriented Technology) and tasked multiple vendors and government offices to work within an integrated product team. At first, bringing order to the many diverse and conflicting views represented on the team seemed as impossible as herding cats. To deal with the project's complexity, the CIOOT project management team developed a process definition technique based on the metaphors of OO technology. The technique brought about common understanding and a clear project plan and, as a bonus, proved valuable for many other practical purposes.

The advantages of standardized evaluation of male infertility.

Healthcare can be improved by standardization and by evaluation of diagnostic methods and treatments. In the field of andrology, in which large patient numbers are required for the evaluation of diagnostic procedures and treatments, structured data collection and multicentre studies are especially warranted. Concomitant with routine clinical practice, a large amount of clinical data are collected that may be used to evaluate andrological care. Structuring and electronic storage of data holds promise in terms of clarity and accessibility of the data and its use for validation studies. The aim of the present work was to study the merits of routine collection of a common dataset in a computer-based patient record (CPR) for standardization, quality of data and clinical research. It was studied whether the data were of sufficient quality and accessibility for much needed studies on aetiology, interventions and diagnostics in andrology. Data collection in a structured CPR promoted complete and comprehensive data. We describe the advantages, pitfalls and solutions with this approach. Data on the uniform examination of 1549 infertile men became readily accessible. Population characteristics, basal associations and original studies were enabled and provided insight into the efficiency of clinical practice. In 66% of men, a cause for their infertility was identified, which provides a better rationale for treatment than semen parameters alone. For more than 30% of the patients, a rational andrological treatment was available, which could be deployed before assisted reproductive technologies were resorted to. However, most treatments have not been properly validated. The thorough diagnostic evaluation identifies subgroups that require an evidence base for treatment and further study on aetiology and diagnosis. Structured collection of uniform patient data through a CPR was feasible and facilitated the evaluation of diagnostic and therapeutic modalities. The reported advantages, pitfalls and solutions with this approach may help other centres to decide on how to implement a CPR. Conscientious collection of a standard data set in infertility centres facilitates pooling of data and evidence-based multicentre research.

Impact of a computer-based patient record system on data collection, knowledge organization, and reasoning.

To assess the effects of a computer-based patient record system on human cognition. Computer-based patient record systems can be considered "cognitive artifacts," which shape the way in which health care workers obtain, organize, and reason with knowledge. Study 1 compared physicians' organization of clinical information in paper-based and computer-based patient records in a diabetes clinic. Study 2 extended the first study to include analysis of doctor-patient-computer interactions, which were recorded on video in their entirety. In Study 3, physicians' interactions with computer-based records were followed through interviews and automatic logging of cases entered in the computer-based patient record. Results indicate that exposure to the computer-based patient record was associated with changes in physicians' information gathering and reasoning strategies. Differences were found in the content and organization of information, with paper records having a narrative structure, while the computer-based records were organized into discrete items of information. The differences in knowledge organization had an effect on data gathering strategies, where the nature of doctor-patient dialogue was influenced by the structure of the computer-based patient record system. Technology has a profound influence in shaping cognitive behavior, and the potential effects of cognition on technology design needs to be explored.

FDA adverse events medwatch program

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Electronic Healthcare Records: an essential part of Health Telematics Applications

A healthcare record should ideally be a repository of data, describing a person's health and how it is being supported; and not, as it is now, describing a person's diseases and treatment only. The healthcare record is the basis for monitoring and decisions. Therefore it should be open and available to all authorized health professionals and to the patient. To make this easier is one of the major advantages of electronic healthcare records (EHCR). The computer-based patient record could make major contributions to improving the healthcare system. This is the motivation to initiatives, projects and routine implementations of electronic patient records. The European Union and national initiatives have put major efforts into the support of this main field of medical information processing.