Computer evaluation of acid-base disorders.

With the advent of electronic computers that operate in the time-sharing mode, it has become possible to develop an automated system that can assist a physician in solving clinical problems. In the present study a teletype terminal has been linked to a time-sharing computer which has been programmed to evaluate clinical and laboratory information concerning patients with acid-base disorders. The program checks the data for evidence of internal consistency and requests additional information as needed to solve the acid-base aspects of the clinical problem. If sufficient information is provided, the program generates an evaluation note designed to review with the physician the pathophysiology of the disorder and to assist him in its management. If the input data are incomplete, the program draws the most useful conclusions possible based on the data provided, specifies the limitations which pertain to these conclusions, suggests further studies designed to circumvent these limitations, and while awaiting the results, suggests appropriate interim therapeutic measures. The time required to enter a patient's data and to print the evaluation note is approximately 4 min; the cost is comparable to that of many laboratory tests.

Effect of computer-based alerts on the treatment and outcomes of hospitalized patients.

BACKGROUND: Hospital computing systems play an important part in the communication of clinical information to physicians. We sought to determine whether computer-based alerts for hospitalized patients can affect physicians' behavior and improve patients' outcomes. METHODS: We performed a prospective time-series study to determine whether computerized alerts to physicians about rising creatinine levels in hospitalized patients receiving nephrotoxic or renally excreted medications led to more rapid adjustment or discontinuation of those medications, and to determine whether such alerts protected renal function. RESULTS: Laboratory data were observed for 20,228 hospitalizations, with documentation of 1573 events (instances of rising creatinine levels during treatment with a nephrotoxic or renally excreted drug). During the intervention period, doses were adjusted or medications discontinued an average of 21.6 hours sooner after such an event (P < .0001). For patients receiving nephrotoxic medications during the intervention period, the relative risk of serious renal impairment was 0.45 (95% confidence interval, 0.22 to 0.94) as compared with the control period, and the mean serum creatinine level was 14.1 mumol/L (0.16 mg/dL) lower on day 3 (P < .01) and 25.6 mumol/L (0.29 mg/dL) lower on day 7 (P < .05) after an event. Forty-four percent of physicians who responded to a questionnaire said that the alerts had been helpful in the care of their patients, whereas 28% found them annoying. Sixty-five percent wished to continue receiving alerts. CONCLUSIONS: Computer-based alerts regarding patients with rising creatinine levels affect physician behavior, prevent serious renal impairment, preserve renal function, and are accepted by clinicians.

Actinic degeneration in association with long-term use of PUVA.

To determine the extent of clinical actinic damage that occurred in association with exposure to oral methoxsalen photochemotherapy (PUVA), dermatologists at 16 university centers assessed the wrinkling, telangiectasia, and altered skin markings on the buttocks and the dorsa of the hands among 1380 patients treated with PUVA. These changes are similar to those seen in skin that is chronically exposed to sunlight. After more than 5 years of prospective study, patients with psoriasis exposed to PUVA showed a significant dose-dependent increase in the prevalence of clinical actinic degeneration of the skin of the buttocks (p less than .05, F-test). The prevalence of moderate or severe change among those patients exposed to high doses of PUVA (more than 160 treatments) was low (11%). The degree of increased clinical actinic degeneration noted on the dorsa of the hands was also significantly related to total exposure to PUVA (p less than .05, F-test). Our findings indicate that long-term PUVA exposure is associated with an increase in clinical actinic degeneration of the skin. However, the magnitude of this increase is small and, after more than 5 years, is of limited clinical consequence to most patients.

Oral methoxsalen photochemotherapy for the treatment of psoriasis: a cooperative clinical trial. 1977.

Extensive psoriasis in 1,308 patients has been treated two or three times a week with oral 8-methoxypsoralen followed by high intensity, long-wave ultraviolet light (PUVA). Excluding 169 patients still under early treatment, psoriasis cleared in 88% and failed to clear in 3%. One percent dropped out due to complications of treatment, and 8% for other reasons. The twice-a-week schedule was superior for patients with lighter skin types. Once a remission was induced, there was no difference in its maintenance when patients were treated once a week, once every other week, or once every third week. Each of these schedules was superior to no maintenance treatment. Immediate side effects of the 45,000 treatments administered in the first 18 months of this study were uncommon, temporary, and generally mild. No clinically significant changes in laboratory screening or eye examinations attributable to PUVA have been uncovered.

Oral methoxsalen photochemotherapy for the treatment of psoriasis: a cooperative clinical trial.

Extensive psoriasis in 1,308 patients has been treated two or three times a week with oral 8-methoxypsoralen followed by high intensity, long-wave ultraviolet light (PUVA). Excluding 169 patients still under early treatment, psoriasis cleared in 88% and failed to clear in 3%. One percent dropped out due to complications of treatment, and 8% for other reasons. The twice-a-week schedule was superior for patients with lighter skin types. Once a remission was induced, there was no difference in its maintenance when patients were treated once a week, once every other week, or once every third week. Each of these schedules was superior to no maintenance treatment. Immediate side effect of the 45,000 treatments administered in the first 18 months of this study were uncommon, temporary, and generally mild. No clinically significant changes in laboratory screening or eye examinations attributable to PUVA have been uncovered.

A computer program that evaluates patients with hypercalcemia.

A computer program has been developed to assist the physician in managing patients with hypercalcemia. The program requests appropriate information, such as the patient's serum calcium concentration, age and x-ray results. Based on the abnormalities detected, the program asks additional questions needed to suggest the most helpful course of action for evaluating or treating the patient's hypercalcemia. As soon as the data have been entered, the program generates an evaluation note that includes diagnostic possibilities, suggestions for additional laboratory studies, therapeutic recommendations and references to the medical literature. The program can be used from any general purpose teletype-compatible terminal (including cathode ray tube displays) connected to the Bell Telephone System. The time required to enter the data and obtain the evaluation note is approximately 4 minutes with a teletypewriter, and less if a faster terminal is used. The cost for computer time is comparable to that of a laboratory test. Comparison of diagnoses produced by the program with those obtained from pathologic examination of from consulting endocrinolgists shows that the program is sufficiently accurate for clinical use. Finnally, the explanation of the pathophysiology contained in the evaluation note may be useful to the student.

The Harvard Cooperative Stroke Registry: a prospective registry.

Data from 694 patients hospitalized with stroke were entered in a prospective, computer-based registry. Three hundred and sixty-four patients (53 percent) were diagnosed as having thrombosis, 215 (31 percent)as having cerebral embolism 70 (10 percent) as having intracerebral hematoma, and 45 (6 percent) as having subarachnoid hemorrhage from aneurysm or arteriovenous malformations. The 364 patients diagnosed as having thrombosis were divided into 233 (34 percent of all 694 patients) whose thrombosis was thought to involve a large artery and 131 (19 percent) with lacunar infarction. Many of the findings in this study were comparable to those in previous registries based on postmortem data. New observations include the high incidence of lacunes and cerebral emboli, the absence of an identifiable cardiac origin in 37 percent of all emboli, a nonsudden onset in 21 percent of emboli, and the occurrence of vomiting at onset in 51 percent and the absence of headache at onset in 67 percent of hematomas.

Medical subject headings used to search the biomedical literature.

The National Library of Medicine's MEDLINE (MEDLARS Online) database was the first database to be searched nationwide via value-added telecommunication networks. Now available on the World Wide Web free of charge from the National Library of Medicine and from many other sources, it is the world's most heavily used medical database. MEDLINE is unique in that each reference to the medical literature is indexed under a controlled vocabulary called Medical Subject Headings (MeSH). These headings are the keys that unlock the medical literature. MeSH multiplies the usefulness of the MEDLINE database and makes it possible to search the medical literature as we do today. This paper commemorates the 40th anniversary of the introduction of MeSH and salutes some of the farsighted persons who conceived and developed the MEDLINE database.

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.

Phototoxic reactions to photoactive drugs in patients treated with PUVA.

To determine the potentially adverse effects of photoactive medications taken in conjunction with oral methoxsalen photochemotherapy (PUVA) for psoriasis, we studied the incidence of phototoxic reactions in 1,125 patients treated with PUVA at 15 centers. During the initial (clearing) phase of PUVA therapy, patients using photoactive medications were no more likely to have diffuse delayed erythema than patients who did not use such medications. After clearing, patients 45 years of age or older who used photoactive drugs were 2.3 times as likely to discontinue PUVA therapy for at least one month owing to problems related to UV-induced burns than were those who did not use such drugs. Only 6% of patients older than 45 years who took photoactive medications had problems with phototoxicity sufficiently severe to contribute to permanent discontinuation of PUVA therapy.

Consulting the computer about acid-base disorders.

A computer program was developed at Beth Israel Hospital in Boston to offer consultation to health care personnel treating patients with electrolyte and acid-base disorders, as the diagnosis of these disorders involves consideration of numerous factors and performance of tedious calculations. In order to obtain the necessary diagnostic information, the computer conducts a dialogue between itself and the person seeking its advice. The program then allows the computer to generate an evaluation note, which lists the diagnostic possibilities, explains the pathophysiology, recommends treatment, and provides references to the medical literature. The entire transaction, from data entry to printing, takes about 4 minutes. The computer program also compensates for entry of inconsistent data and for lack of data. Our experience with the program has revealed that it has favorably influenced patient care in a number of cases and has helped our staff better understand the pathophysiology and treatment of electrolyte and acid-base disorders.

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.

Why good hospitals get bad computing.

American Hospitals spend a lot of money for computing, but physicians and nurses are dissatisfied with the computing that they receive. No one is at fault. Rather, each person, acting in his or her best interest, unwittingly conspires to produce the unfavorable result. Until hospitals make major and fundamental changes in the way they purchase and manage computing, they will continue to spend large sums without commensurate return.

PaperChase: computerized bibliographical retrieval for the physician.

PaperChase is a computer program that permits any physician or scientist to search the National Library of Medicine's MEDLINE data base of references to the biomedical literature. Written for the clinician rather than for the search librarian, PaperChase permits the user to search the entire MEDLINE collection of over 5,000,000 references published in 4,000 biomedical journals dating back to 1966. PaperChase is now available throughout the world to anyone who has a computer terminal or personal computer, and a modem. No special training is needed for a successful search. There is no user's manual. Users can search by title word, Medical Subject Heading, author's name, journal title, year of publication, language of publication, or any combination of the above. Users can read abstracts online, and they can request that a photocopy of the full text of any article be mailed to them.