Transcript 1999-Holynm-Bringing Clinical Information to the Bedside with the

Bringing Clinical Information
to the Bedside with the World
Wide Web
James J. Cimino, M.D.
Departments of Medicine and Medical Informatics
Columbia University
First Admission: August, 1983
In August, 1983, a 50 year old male presented to
the St. Vincent’s Hospital (NY) emergency room
with a scalp laceration due to a falling paint can.
The wound was cleaned and sutured, and the
patient was given a follow up appointment for
surgery clinic. Two weeks later, the patient was
seen at the scheduled clinic visit and was found
to have delayed healing of one portion of the
wound. After several weekly visits, the poorlyhealing area was excised and the wound was
closed. The patient had a good result and was
discharged from further follow up.
Second Admission - March, 1984
The patient was brought to the emergency room
for recent increasing lethargy. Laboratory
evaluation was remarkable only for a calcium of
17 mg/dl. The patient was treated aggressively
with hydration and diuretics, but expired shortly
after admission. A diagnostic report was
received.
Prologue as Epilogue
The pathology report from the wound
revision the previous September included
the following phrase:
“Metastatic adenocarcinoma of
uncertain origin is noted at the
tissue margins”
What Happened?
• The surgeons didn’t know to follow up
• The pathologists assumed someone
would read their report
• No one was making sure that the ball
didn’t get dropped
How Could Computers Help?
• The report would not fall through the cracks
• Route the report to the right person
• Generate an alert
• Check to see if someone read the report/alert
How Can the Web Help?
• Ubiquitous (bi-directional) access
• Bring together information from multiple
systems
• Access to on-line health information
resources
• Integration of information resources and
clinical applications
Laboratory
Data Entry
& Results
Review
Event
Monitor
Medical
Logic
Modules
Billing &
Financial
Specialized
Encoders
MedLEE
Pharmacy
Database
Interface
Medical
Entities
Dictionary
Radiology
Patient
Database
Research
Databases
Volume
• No data are deleted
• 100 K bytes / patient
• 100 K patients / year
• 10 Gigabytes / year
CIS Daily Inquiries (weekdays)
March '97
Inquiries/day
7547
2022 2046
1114
639
700
559
514
104
LAB
RAD
DEM PATH Adm Disch CAR
Op.
396
Phar Other
Physician Use
Clinical Information System Utilization Over Time
Peak vs. Other hours
16000
14000
Peak (2-5pm)
Normal (8am-2pm)
Low (midnight to 8am)
10000
8000
6000
4000
2000
1997
Sept
1996
Sept
1995
Sept
1994
Sept
1993
Sept
1992
Sept
1991
Sept
0
1990
# of screens/hour
12000
Physician Use
CIS Utilization
House Staff vs. Attendings
March 1997
100
90
% using CIS System
80
70
60
House
officers
50
Attendings
40
30
20
10
0
MED
NEU
OBG
ORT
PED
PSY
SUR
URO
OTHER
Clinical MLMs: Alerts
SUBJECT
PERCENT
VIEWED
VIEWINGS /
EVENT
EVENTS /
MONTH
NUMBER OF
MLMs
positive TB culture
73.5
7.5
34.3
1
creatinine rise
hypokalemia and digoxin use
newborn with HBV positive
mother
hypokalemia and diuretic
use
renal failure and
aminoglycoside use
renal failure and NSAID use
63.1
57.5
55.0
3.1
2.1
1.9
254.1
87.1
12.5
1
3
2
48.0
1.6
66
2
41.7
1.6
56
2
34.8
1.8
139
2
new anemia
32.4
2.1
430.7
1
WebCIS
• Web-based Clinical Information System
• For use by clinicians (doctors, nurses, students)
• Access to all data in the repository
• Access to on-line information resources
Things You Can Do On the Web
• Read a newspaper
• Buy groceries
• Banking
• Trade stocks
• Track your Fed Ex package
• Get health information
Health Information You Can Get
• Medline citations
• Drug advertisements
• Quack therapies
• Viagra prescriptions
Health Information You Can’t Get
• Your cholesterol level
• Your mammogram report
• A list of your current medications
• Advice from your doctor
Personal Health Information on the Web
• Access to your electronic medical record
• Ability to contribute to your medical record
• Relevant, reliable, understandable advice
• Fostering patient-clinician communication
PatCIS: An Experiment with
Patient Access
• Funded by the US National Library of Medince
• Data entry
• Data review
• Education
• Advice
• “Infobuttons”
Potential Areas of Expansion
• Lab test interpretation
• Pap smear infobutton
• Medication lists
• Advance directives
Addressing the Challenges
• Web access to records
• Security and confidentiality issues
• Political issues
• Ethical issues
Ethical Issues
• Discovery without supervision
• Misunderstanding and worry
• Misunderstanding and complacency
• Patient-clinician communications
– better
– shorter
– worse
– longer
Conclusions
• Web access to clinical information is feasible
for clinicians and patients
• The Web offers innovative ways to view data
• Integration of clinical systems and decision
support tools is possible
• Infrastructure is crucial
• Cognitive issues are under study