The federal role in the health information infrastructure: a debate of the pros and cons of government intervention.

Some observers feel that the federal government should play a more active leadership role in educating the medical community and in coordinating and encouraging a more rapid and effective implementation of clinically relevant applications of wide-area networking. Other people argue that the private sector is recognizing the importance of these issues and will, when the market demands it, adopt and enhance the telecommunications systems that are needed to produce effective uses of the National Information Infrastructure (NII) by the healthcare community. This debate identifies five areas for possible government involvement: convening groups for the development of standards; providing funding for research and development; ensuring the equitable distribution of resources, particularly to places and people considered by private enterprise to provide low opportunities for profit; protecting rights of privacy, intellectual property, and security; and overcoming the jurisdictional barriers to cooperation, particularly when states offer conflicting regulations. Arguments against government involvement include the likely emergence of an adequate infrastructure under free market forces, the often stifling effect of regulation, and the need to avoid a common-and-control mentality in an infrastructure that is best promoted collaboratively.

Rational staffing of hospital nursing services by functional activity budgeting.

Nursing services are a costly item in the hospital budget, yet their justification is usually based on precedent and anecdote. Patient classification systems enable quantification of the nursing load on a daily basis. This methodology for determining the size of the nursing staff, however, has not gained widespread use because it tends to formalize existing staffing patterns. At the Johns Hopkins Hospital, physicians and nurses drew up a list of activities that should be performed for patients and that need to be considered in budgeting for nursing services. The largest and most variable components of the nursing workload are the tasks specified by physicians' orders and the nursing care plan. A computerized information system which communicates these orders can also be used to quantify these components of the nursing workload, since standard times to perform these tasks have been documented. The variability of these tasks from day to day and from patient to patient is the source of most of the problems of staffing. Other components of the workload, such as patient education, depend on the nursing program desired and must be added separately. Budget decisions can then be based upon the specific nursing functions which the hospital desires to perform. The technique of functional activity budgeting can also be used for the utilization review of physicians' use of nursing services.

The case for the HL7 standard.

An effort begun in the spring of 1987 by a group of executives within the healthcare industry to establish a Level 7 networking standard (HL7) is rapidly gaining momentum. This article discusses a draft Level 7 protocol which has been produced to ease the complications inherent in the multi-vendor environment of healthcare communications.

Networking and medical information systems.

A local area communications network (LACN) has been implemented successfully at the University of California, San Francisco (UCSF) Hospital. This technology, developed by the Applied Physics Laboratory of the Johns Hopkins University, facilitates communication among systems previously considered "incompatible". The implication of this experiment is that a modular, evolutionary approach to medical systems will soon be a viable alternative to the "total" single-vendor approach now commonly used. Substantial preparation by a medical center, however, will be required in order to use an LACN properly. This will probably be done in many cases with the assistance of a new type of medical systems vendor, i.e., one having no systems of its own to sell.

Medication prescribing on a university medical service-the incidence of drug combinations with potential adverse interactions.

The medication prescribing practices on a University medical service were reviewed for a two year period. 103,484 medication orders were analyzed for 6,864 patient admissions. Forty drugs account for 64% of all medication orders. One hundred drugs account for 86% of all medication orders. During the two year period the incidence of prescribing specific drug combinations with potential adverse interactions varied from three to one hundred seventeen instances among the combinations examined. Review of a sample of those patients receiving the combination of spironolactone and oral potassium chloride showed that 52% developed hyperkalemia. These results suggest that when physicians prescribe drug combinations with potentially adverse interactions they may not always institute appropriate surveillance to prevent adverse consequences. A trial of automated monitoring of medication orders with appropriate physician feedback has begun as a result of these findings.

Riding the right horse. Interview by Eric Skjei.

To date, 14 hospitals have decided to install a "systems integration product that adds value to a network technology." According to its progenitor, the product also maximizes the flexibility of departments in choosing the right product for their specific needs. CIH talked with Dr. Simborg recently about his system model and philosophy.

A highly automated hospital medication system. Five years' experience and evaluation.

Since 1969, medications have been provided to patients at the Johns Hopkins Hospital using a computer system that controls the entire medication process from entry of physician's order to hourly drug distribution. Special envelopes containing patient and dosage information are computer generated for each dose to be administered. These envelopes, containing individually labelled ready-to-administer doses, are delivered to the nursing units hourly. The system provides daily medication profiles, drug administration histories, discharge summaries, and management and billing reports. Medication errors of commission were 4.6 times more frequent on the traditional nursing units compared to the units with the computer system. Registered nurses spend 56% less time performing medication-related activities on the units served by the computer. For 250 beds, total costs are 7% higher using the computer system. For 450 beds, total costs are 14% lower using the computer system.

Physicians and non-physician health practitioners: the characteristics of their practices and their relationships.

Six primary care practices which utilize both physician and non-physician practitioner types were studied to measure differences between practitioner types in the care of patients. By chart review 1,369 patient-practitioner encounters were examined. Physicians identified less symptoms and signs in their patients and prescribed less non-drug therapies than did non-physicians. Likewise, at follow-up visits, physicians tended to document less follow-up of these types of problems and therapies than non-physicians. When examining the interaction between practitioners, the highest rates of follow-up of all types of problems and therapies were found when the same practitioner saw the patient at two successive visits to the same clinic. When a physician saw a patient following a previous visit to a nurse practitioner, there was a significant drop-off in the follow-up rate of problems and therapies. However, when a nurse practitioner saw the patient following a previous visit to a physician, the drop-off in follow-up rates was not as striking. These findings indicate that the skills of physician and nonphysician practitioners are potentially complementary. However, this potential is not fully exploited, particularly by physicians.

Evaluation methodology for ambulatory care information systems.

The central purpose of an ambulatory care information system is to communicate information to the practitioner to facilitate clinical decision making. The clinical decision can be considered the dependent output variable in a process in which the information system, the patient, clinician characteristics and the environment are the independent input variables. Evaluation methodologies must consider there relationships. Approaches using patients outcomes are problematic because of indirect relationship between the information system and patient outcomes, which limits both sensitivity and validity. A process measure technique that focuses on the clinical decision directly as the measure of output could be appropriate if the represented a generic sampling of clinical decisions made in ambulatory care. A new method under development based on an information theory concept may be more widely applicable than currently available methods.

The Johns Hopkins radiology reporting system.

Radiologists can comprehensively report diagnostic radiographs by computer with a speed approaching that of dictation. This is the main mode of radiographic reporting used at the Johns Hopkins Hospital. Support functions include information storage, retrieval, statistics, and billing. Costs are comparable to stenography. The system can be run from a large time-sharing computer or dedicated minicomputer. A commercial stand-alone version will soon be available.

Choosing the correct unit of analysis in Medical Care experiments.

The statistical methodology of health research experiments published in Lancet, the New England Journal of Medicine, and Medical Care between 1975 and 1980 for the presence or absence of an error of experimental design and analysis was examined. The error is the result of inappropriately using patient-related observations as the unit of analysis to form conclusions about provider behavior or outcomes determined jointly by patients and providers. The error was present in 20 of 28 (71%) health care experiments addressing an issue of health provider professional performance. Its usual effect is to increase erroneously the power of an experiment to detect differences between experimental and control groups. It is likely that this type of error could be avoided by the explicit and prospective definition of hypotheses and the populations to which they are intended to pertain.

A controlled experiment to evaluate the use of a time-oriented summary medical record.

A randomized single-blind experiment was done in a medical subspecialty clinic in order to determine whether a flow-sheet type of summary medical record could validly serve as a means to communicate clinical information in the absence of the traditional medical record. Two groups of outpatient physician-patient encounters were compared: In the 68 study encounters (Group S), physicians were given a flow-sheet summary record with the option to receive the standard medical record if they desired; in the 27 control encounters (Group C), physicians were given the standard medical record plus the flow-sheet summary record. Fifty-nine per cent of study-group physicians did not choose to receive the full medical record. The study group was found not to differ (p = 0.013) from controls significantly with regard to the follow-up of clinical information as measured by pre- and post-encounter chart review. Physician providers in the study group were unable to detect by retrospective chart review overlooked clinical information with greater frequency than control group providers. We conclude that a flow-sheet type of summary medical record can serve as the sole source of clinical information in a substantial number of outpatient follow-up encounters in a medical subspecialty clinic without deterioration in the communication of clinical information.

Classification of ambulatory care using patient-based, time-oriented indexes.

This paper presents a new approach to the classification of ambulatory care into isoresource consumption groups. In contrast to classification schemes based on visits, this case-mix approach creates an index based on resources used by diagnostic categories by a patient during a year. An application of this method to a primary care, group practice data base produced resource consumption groups with coefficients of variation in an acceptable range compared with the coefficients of variation of the diagnosis-related groups used to classify inpatient care.

A computerized summary medical record system can provide more information than the standard medical record.

We assessed the ability of a computerized outpatient medical record (MR) system, the Summary Time-Oriented Record (STOR), to communicate information to clinicians in two randomized single-blind studies. In the first study, physicians were better able to predict their patients' future symptom changes and laboratory test results from outpatient visits to an arthritis clinic when STOR was added to the standard MR than when the standard MR was used alone. In a separate study, the removal of the standard MR did not result in important decrease in the physicians' ability to predict their patients' symptoms and laboratory test results if they had the option of using the full paper record when they thought they needed it. In 134 (26%) of 514 visits, the physicians exercised this option. We conclude that for outpatient visits, the computerized record system STOR operationally added information to that supplied by the full paper MR. This improved flow of information could improve the clinical decision process.

Information factors affecting problem follow-up in ambulatory care.

The influence of information factors on the follow-up of patient problems was studied in six ambulatory clinics providing primary patient care. By means of chart review, the encounter notes were examined for two consecutive visits to the same clinic to determine problems identified at the first visit and detect evidence of follow-up of these problems at the second visit. In those clinics using a problem list, at the front of the chart, those problems on the problem list had a higher follow-up rate than those not on the list particularly at longer intervals between patient visits. An encounter note written in the problem-oriented format did not enhance follow-up. Since information factors as well as clinical factors affect the follow-up of patient problems these factors must be carefully considered when designing information systems to serve ambulatory care.

Continuity and coordination in primary care: their achievement and utility.

Coordination is a hallmark of primary care. Efforts to improve primary care services should involve assessment of the extent to which coordination is achieved. Our study in three adult and three pediatric clinics demonstrates that existing information concerning patients' problems, therapies, tests, and referrals is often not recognized by primary care practitioners. Recognition of these types of information is better when the practitioner who provides follow-up care is the same from one visit to the next. Information about visits which were anticipated by the practitioner, and particularly the content of these visits, is often neglected. The largest deficit, however, is in recognition of both the occurrence and content of visits unanticipated by the primary care practitioner. Greater efforts to achieve better coordination of care, by improving either continuity of practitioner, communication among practitioners, or the information system, are required before this essential element of primary care becomes a reality.

A minirecord: an aid to continuity of care.

A simple, low cost computerized minirecord system (minimal essential record) has been in full operation for two years in the Medical Clinic of The Johns Hopkins Hospital. The primary objective of the minirecord system is to permit rapid retrieval of current information concerning Medical Clinic patients. The system provides a computer-printed listing of problems and medications in the front of each chart and on-line display of this information at strategically located computer terminals. The information is generated via existing simple systems with minimal additional effort and with the use of any terminology deemed appropriate. Chart review revealed that minirecords were actually present in 92% of the charts and that significant improvement occurred in the recognition of a subsequent visit of clearly defined problems and therapies noted on the initial minirecord. Current modifications will replace the separate minirecord and encounter form (registration and visit note) with a single form that will facilitate completion an updating. The rapid availability of this information provides a mechanism for coordinating continuing care in a university hospital system that is otherwise inevitably fragmented and composed of multiple health care providers.

Computer-assisted radiology reporting: quality of reports.

Automated medical communication systems for patient care usually enhance timeliness and retrievability. The effect of automated systems on communication quality has not been sufficiently measured. The radiology reports produced with the automated radiology reporting system at the Johns Hopkins Hospital were evalueate for quality and compared to reports produced by dictation. No differences in quality between computer-generated and dictated reports were detected by three consultant radiologists using a specially designed quality rating system.