Clinicians perceptions of a telemedicine system: a mixed method study of Makassar City, Indonesia.

BACKGROUND: This case study in Makassar City, Indonesia aims to investigate the clinicians' perceptions, including both satisfaction and barriers in using telemedicine in a large, established program which supported 3974 consultations in 2017. METHODS: A mixed methodology was used in this research utilizing a questionnaire with 12 questions, and semi-structured interviews. A purposeful sample of clinicians using the telemedicine system at the 39 primary care clinics in Makassar City were surveyed. A total of 100 clinicians participated in this study. All of them completed the questionnaires (76.9% response rate) and 15 of them were interviewed. RESULTS: The result showed that 78% of the clinicians were satisfied with the telemedicine system. In free text responses 69% said that telemedicine allowed quicker diagnosis and treatment, 47% said poor internet connectivity was a significant obstacle in using the system, and 40% suggested improvement to the infrastructure including internet connection and electricity. CONCLUSION: Overall, the clinicians were satisfied with the system, with the main benefit of rendering the diagnosis faster and easier for patients. However, poor internet connectivity was indicated as the main barrier. Most of the clinicians suggested improving the infrastructure especially the internet network.

Factors Influencing Data Quality in Electronic Health Record Systems in 50 Health Facilities in Rwanda and the Role of Clinical Alerts: Cross-Sectional Observational Study.

BACKGROUND: Electronic health records (EHRs) play an increasingly important role in delivering HIV care in low- and middle-income countries. The data collected are used for direct clinical care, quality improvement, program monitoring, public health interventions, and research. Despite widespread EHR use for HIV care in African countries, challenges remain, especially in collecting high-quality data. OBJECTIVE: We aimed to assess data completeness, accuracy, and timeliness compared to paper-based records, and factors influencing data quality in a large-scale EHR deployment in Rwanda. METHODS: We randomly selected 50 health facilities (HFs) using OpenMRS, an EHR system that supports HIV care in Rwanda, and performed a data quality evaluation. All HFs were part of a larger randomized controlled trial, with 25 HFs receiving an enhanced EHR with clinical decision support systems. Trained data collectors visited the 50 HFs to collect 28 variables from the paper charts and the EHR system using the Open Data Kit app. We measured data completeness, timeliness, and the degree of matching of the data in paper and EHR records, and calculated concordance scores. Factors potentially affecting data quality were drawn from a previous survey of users in the 50 HFs. RESULTS: We randomly selected 3467 patient records, reviewing both paper and EHR copies (194,152 total data items). Data completeness was >85% threshold for all data elements except viral load (VL) results, second-line, and third-line drug regimens. Matching scores for data values were close to or >85% threshold, except for dates, particularly for drug pickups and VL. The mean data concordance was 10.2 (SD 1.28) for 15 (68%) variables. HF and user factors (eg, years of EHR use, technology experience, EHR availability and uptime, and intervention status) were tested for correlation with data quality measures. EHR system availability and uptime was positively correlated with concordance, whereas users' experience with technology was negatively correlated with concordance. The alerts for missing VL results implemented at 11 intervention HFs showed clear evidence of improving timeliness and completeness of initially low matching of VL results in the EHRs and paper records (11.9%-26.7%; P<.001). Similar effects were seen on the completeness of the recording of medication pickups (18.7%-32.6%; P<.001). CONCLUSIONS: The EHR records in the 50 HFs generally had high levels of completeness except for VL results. Matching results were close to or >85% threshold for nondate variables. Higher EHR stability and uptime, and alerts for entering VL both strongly improved data quality. Most data were considered fit for purpose, but more regular data quality assessments, training, and technical improvements in EHR forms, data reports, and alerts are recommended. The application of quality improvement techniques described in this study should benefit a wide range of HFs and data uses for clinical care, public health, and disease surveillance.

The Global Health Informatics landscape and JAMIA.

Global Health Informatics (GHI) as a branch of health informatics has been established for 2 decades now. During that time, great strides have been made in the creation and implementation of informatics tools to improve healthcare delivery and outcomes in the most vulnerable and remote communities worldwide. In many of the most successful projects, innovation has been shared between teams in high- and low- or middle-income countries (LMICs). In this perspective, we review the state of the academic field of GHI and the work published in JAMIA in the last 6 1/2 years. We apply criteria for articles about LMICs, those on international health, and on indigenous and refugee population, and subtypes of research. For comparison, we apply those criteria to JAMIA Open and 3 other health informatics journals which publish articles on GHI. We make recommendations for future directions and the role that journals like JAMIA can play in strengthening this work worldwide.

Impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here?

E-health encompasses a diverse set of informatics tools that have been designed to improve public health and health care. Little information is available on the impacts of e-health programmes, particularly in low- and middle-income countries. We therefore conducted a scoping review of the published and non-published literature to identify data on the effects of e-health on health outcomes and costs. The emphasis was on the identification of unanswered questions for future research, particularly on topics relevant to low- and middle-income countries. Although e-health tools supporting clinical practice have growing penetration globally, there is more evidence of benefits for tools that support clinical decisions and laboratory information systems than for those that support picture archiving and communication systems. Community information systems for disease surveillance have been implemented successfully in several low- and middle-income countries. Although information on outcomes is generally lacking, a large project in Brazil has documented notable impacts on health-system efficiency. Meta-analyses and rigorous trials have documented the benefits of text messaging for improving outcomes such as patients' self-care. Automated telephone monitoring and self-care support calls have been shown to improve some outcomes of chronic disease management, such as glycaemia and blood pressure control, in low- and middle-income countries. Although large programmes for e-health implementation and research are being conducted in many low- and middle-income countries, more information on the impacts of e-health on outcomes and costs in these settings is still needed.

Adaptation of a web-based, open source electronic medical record system platform to support a large study of tuberculosis epidemiology.

BACKGROUND: In 2006, we were funded by the US National Institutes of Health to implement a study of tuberculosis epidemiology in Peru. The study required a secure information system to manage data from a target goal of 16,000 subjects who needed to be followed for at least one year. With previous experience in the development and deployment of web-based medical record systems for TB treatment in Peru, we chose to use the OpenMRS open source electronic medical record system platform to develop the study information system. Supported by a core technical and management team and a large and growing worldwide community, OpenMRS is now being used in more than 40 developing countries. We adapted the OpenMRS platform to better support foreign languages. We added a new module to support double data entry, linkage to an existing laboratory information system, automatic upload of GPS data from handheld devices, and better security and auditing of data changes. We added new reports for study managers, and developed data extraction tools for research staff and statisticians. Further adaptation to handle direct entry of laboratory data occurred after the study was launched. RESULTS: Data collection in the OpenMRS system began in September 2009. By August 2011 a total of 9,256 participants had been enrolled, 102,274 forms and 13,829 laboratory results had been entered, and there were 208 users. The system is now entirely supported by the Peruvian study staff and programmers. CONCLUSIONS: The information system served the study objectives well despite requiring some significant adaptations mid-stream. OpenMRS has more tools and capabilities than it did in 2008, and requires less adaptations for future projects. OpenMRS can be an effective research data system in resource poor environments, especially for organizations using or considering it for clinical care as well as research.

A Graphical Toolkit for Longitudinal Dataset Maintenance and Predictive Model Training in Health Care.

BACKGROUND: Predictive analytic models, including machine learning (ML) models, are increasingly integrated into electronic health record (EHR)-based decision support tools for clinicians. These models have the potential to improve care, but are challenging to internally validate, implement, and maintain over the long term. Principles of ML operations (MLOps) may inform development of infrastructure to support the entire ML lifecycle, from feature selection to long-term model deployment and retraining. OBJECTIVES: This study aimed to present the conceptual prototypes for a novel predictive model management system and to evaluate the acceptability of the system among three groups of end users. METHODS: Based on principles of user-centered software design, human-computer interaction, and ethical design, we created graphical prototypes of a web-based MLOps interface to support the construction, deployment, and maintenance of models using EHR data. To assess the acceptability of the interface, we conducted semistructured user interviews with three groups of users (health informaticians, clinical and data stakeholders, chief information officers) and evaluated preliminary usability using the System Usability Scale (SUS). We subsequently revised prototypes based on user input and developed user case studies. RESULTS: Our prototypes include design frameworks for feature selection, model training, deployment, long-term maintenance, visualization over time, and cross-functional collaboration. Users were able to complete 71% of prompted tasks without assistance. The average SUS score of the initial prototype was 75.8 out of 100, translating to a percentile range of 70 to 79, a letter grade of B, and an adjective rating of "good." We reviewed persona-based case studies that illustrate functionalities of this novel prototype. CONCLUSION: The initial graphical prototypes of this MLOps system are preliminarily usable and demonstrate an unmet need within the clinical informatics landscape.

User Perceptions and Use of an Enhanced Electronic Health Record in Rwanda With and Without Clinical Alerts: Cross-sectional Survey.

BACKGROUND: Electronic health records (EHRs) have been implemented in many low-resource settings but lack strong evidence for usability, use, user confidence, scalability, and sustainability. OBJECTIVE: This study aimed to evaluate staff use and perceptions of an EHR widely used for HIV care in >300 health facilities in Rwanda, providing evidence on factors influencing current performance, scalability, and sustainability. METHODS: A randomized, cross-sectional, structured interview survey of health center staff was designed to assess functionality, use, and attitudes toward the EHR and clinical alerts. This study used the associated randomized clinical trial study sample (56/112, 50% sites received an enhanced EHR), pulling 27 (50%) sites from each group. Free-text comments were analyzed thematically using inductive coding. RESULTS: Of the 100 participants, 90 (90% response rate) were interviewed at 54 health centers: 44 (49%) participants were clinical and 46 (51%) were technical. The EHR top uses were to access client data easily or quickly (62/90, 69%), update patient records (56/89, 63%), create new patient records (49/88, 56%), generate various reports (38/85, 45%), and review previous records (43/89, 48%). In addition, >90% (81/90) of respondents agreed that the EHR made it easier to make informed decisions, was worth using, and has improved patient information quality. Regarding availability, (66/88) 75% said they could always or almost always count on the EHR being available, whereas (6/88) 7% said never/almost never. In intervention sites, staff were significantly more likely to update existing records (P=.04), generate summaries before (P<.001) or during visits (P=.01), and agree that "the EHR provides useful alerts, and reminders" (P<.01). CONCLUSIONS: Most users perceived the EHR as well accepted, appropriate, and effective for use in low-resource settings despite infrastructure limitation in 25% (22/88) of the sites. The implementation of EHR enhancements can improve the perceived usefulness and use of key functions. Successful scale-up and use of EHRs in small health facilities could improve clinical documentation, care, reporting, and disease surveillance in low- and middle-income countries.

Evaluation of Diagnostic and Triage Accuracy and Usability of a Symptom Checker in an Emergency Department: Observational Study.

BACKGROUND: Symptom checkers are clinical decision support apps for patients, used by tens of millions of people annually. They are designed to provide diagnostic and triage advice and assist users in seeking the appropriate level of care. Little evidence is available regarding their diagnostic and triage accuracy with direct use by patients for urgent conditions. OBJECTIVE: The aim of this study is to determine the diagnostic and triage accuracy and usability of a symptom checker in use by patients presenting to an emergency department (ED). METHODS: We recruited a convenience sample of English-speaking patients presenting for care in an urban ED. Each consenting patient used a leading symptom checker from Ada Health before the ED evaluation. Diagnostic accuracy was evaluated by comparing the symptom checker's diagnoses and those of 3 independent emergency physicians viewing the patient-entered symptom data, with the final diagnoses from the ED evaluation. The Ada diagnoses and triage were also critiqued by the independent physicians. The patients completed a usability survey based on the Technology Acceptance Model. RESULTS: A total of 40 (80%) of the 50 participants approached completed the symptom checker assessment and usability survey. Their mean age was 39.3 (SD 15.9; range 18-76) years, and they were 65% (26/40) female, 68% (27/40) White, 48% (19/40) Hispanic or Latino, and 13% (5/40) Black or African American. Some cases had missing data or a lack of a clear ED diagnosis; 75% (30/40) were included in the analysis of diagnosis, and 93% (37/40) for triage. The sensitivity for at least one of the final ED diagnoses by Ada (based on its top 5 diagnoses) was 70% (95% CI 54%-86%), close to the mean sensitivity for the 3 physicians (on their top 3 diagnoses) of 68.9%. The physicians rated the Ada triage decisions as 62% (23/37) fully agree and 24% (9/37) safe but too cautious. It was rated as unsafe and too risky in 22% (8/37) of cases by at least one physician, in 14% (5/37) of cases by at least two physicians, and in 5% (2/37) of cases by all 3 physicians. Usability was rated highly; participants agreed or strongly agreed with the 7 Technology Acceptance Model usability questions with a mean score of 84.6%, although "satisfaction" and "enjoyment" were rated low. CONCLUSIONS: This study provides preliminary evidence that a symptom checker can provide acceptable usability and diagnostic accuracy for patients with various urgent conditions. A total of 14% (5/37) of symptom checker triage recommendations were deemed unsafe and too risky by at least two physicians based on the symptoms recorded, similar to the results of studies on telephone and nurse triage. Larger studies are needed of diagnosis and triage performance with direct patient use in different clinical environments.

Comprehensive treatment of extensively drug-resistant tuberculosis.

BACKGROUND: Extensively drug-resistant tuberculosis has been reported in 45 countries, including countries with limited resources and a high burden of tuberculosis. We describe the management of extensively drug-resistant tuberculosis and treatment outcomes among patients who were referred for individualized outpatient therapy in Peru. METHODS: A total of 810 patients were referred for free individualized therapy, including drug treatment, resective surgery, adverse-event management, and nutritional and psychosocial support. We tested isolates from 651 patients for extensively drug-resistant tuberculosis and developed regimens that included five or more drugs to which the infecting isolate was not resistant. RESULTS: Of the 651 patients tested, 48 (7.4%) had extensively drug-resistant tuberculosis; the remaining 603 patients had multidrug-resistant tuberculosis. The patients with extensively drug-resistant tuberculosis had undergone more treatment than the other patients (mean [+/-SD] number of regimens, 4.2+/-1.9 vs. 3.2+/-1.6; P<0.001) and had isolates that were resistant to more drugs (number of drugs, 8.4+/-1.1 vs. 5.3+/-1.5; P<0.001). None of the patients with extensively drug-resistant tuberculosis were coinfected with the human immunodeficiency virus (HIV). Patients with extensively drug-resistant tuberculosis received daily, supervised therapy with an average of 5.3+/-1.3 drugs, including cycloserine, an injectable drug, and a fluoroquinolone. Twenty-nine of these patients (60.4%) completed treatment or were cured, as compared with 400 patients (66.3%) with multidrug-resistant tuberculosis (P=0.36). CONCLUSIONS: Extensively drug-resistant tuberculosis can be cured in HIV-negative patients through outpatient treatment, even in those who have received multiple prior courses of therapy for tuberculosis.

Using electronic medical records for HIV care in rural Rwanda.

Partners In Health (PIH) implemented an electronic medical record (EMR) system in Rwanda in 2005 to support and improve HIV and TB patient care. The system holds detailed patient records, accessible to clinicians through printed reports or directly via a computer in the consultation rooms. Ongoing assessment of data quality and clinical data use has led multiple interventions to be put in place. One such evaluation cycle led to the implementation of a system which identified 15 previously undiagnosed pediatric patients with HIV. Another cycle led to an EMR intervention which helped to decrease the proportion of completed critical CD4 lab results that did not reach clinicians by 34.2% (p=.002). Additionally an automated data quality improvement system reduced known errors by 92% by providing local data officers a tool and training to allow them to easily access and correct data errors. Electronic systems can be used to support care in rural resource-poor settings, and frequent assessment of data quality and clinical use of data can be used to support that goal.

Experience implementing a point-of-care electronic medical record system for primary care in Malawi.

Due to the fact that health care professionals in Malawi are often overstretched, the use and quality of health data can be compromised. The Malawi Health Management Information System (HMIS) has streamlined data collection and reporting and increased the use of data to improve care. Obstacles remain, including incomplete reporting and low staff morale. With the Baobab Health Trust and the Malawi Ministry of Health, Partners In Health piloted an innovative point-of-care data system for primary care that functions alongside OpenMRS, an open source medical record platform. The system has given access to a patient-level primary care dataset in real time. Initial results highlight some of the benefits of a point-of-care system such as improved data quality, emphasize the importance of sharing data with clinical practitioners, and shed light on how this approach could strengthen HMIS.

Training software developers for electronic medical records in Rwanda.

In many developing countries, electronic medical record (EMR) systems are being implemented in resource-poor settings. Essential to such implementations are software developers with a high technical capacity, a good understanding of medical informatics and an awareness of local clinical needs. This paper describes a training program which has been run in Rwanda to enable local computer science graduates to play a significant role in that country's forthcoming implementation of a national EMR system. Such a training program is unique in that region of Africa and we discuss the challenges inherent in such an undertaking. We describe the development of the curriculum and the evolution of the teaching methodologies over the course of the year and discuss its potential integration with academic institutions in Rwanda. Finally we propose that training programs of this nature which produce local software developers who are familiar with medical informatics are a requirement for successful and sustainable eHealth implementations in the developing world.

Barriers to the success of an electronic pharmacovigilance reporting system in Kenya: an evaluation three years post implementation.

Objective: Electronic pharmacovigilance reporting systems are being implemented in many developing countries in an effort to improve reporting rates. This study sought to establish the factors that acted as barriers to the success of an electronic pharmacovigilance reporting system in Kenya 3 years after its implementation. Materials and Methods: Factors that could act as barriers to using electronic reporting systems were identified in a review of literature and then used to develop a survey questionnaire that was administered to pharmacists working in government hospitals in 6 counties in Kenya. Results: The survey was completed by 103 out of the 115 targeted pharmacists (89.5%) and included free-text comments. The key factors identified as barriers were: unavailable, unreliable, or expensive Internet access; challenges associated with a hybrid system of paper and electronic reporting tools; and system usability issues. Coordination challenges at the national pharmacovigilance center and changes in the structure of health management in the country also had an impact on the success of the electronic reporting system. Discussion: Different personal, organizational, infrastructural, and reporting system factors affect the success of electronic reporting systems in different ways, depending on the context. Context-specific formative evaluations are useful in establishing the performance of electronic reporting systems to identify problems and ensure that they achieve the desired objectives. Conclusion: While several factors hindered the optimal use of the electronic pharmacovigilance reporting system in Kenya, all were considered modifiable. Effort should be directed toward tackling the identified issues in order to facilitate use and improve pharmacovigilance reporting rates.

Information systems for patient follow-up and chronic management of HIV and tuberculosis: a life-saving technology in resource-poor areas.

BACKGROUND: The scale-up of treatment for HIV and multidrug-resistant tuberculosis (MDR-TB) in developing countries requires a long-term relationship with the patient, accurate and accessible records of each patient's history, and methods to track his/her progress. Recent studies have shown up to 24% loss to follow-up of HIV patients in Africa during treatment and many patients not being started on treatment at all. Some programs for prevention of maternal-child transmission have more than 80% loss to follow-up of babies born to HIV-positive mothers. These patients are at great risk of dying or developing drug resistance if their antiretroviral therapy is interrupted. Similar problems have been found in the scale-up of MDR-TB treatment. OBJECTIVES: The aim of the study was to assess the role of medical information systems in tracking patients with HIV or MDR-TB, ensuring they are promptly started on high quality care, and reducing loss to follow-up. METHODS: A literature search was conducted starting from a previous review and using Medline and Google Scholar. Due to the nature of this work and the relative lack of published articles to date, the authors also relied on personal knowledge and experience of systems in use and their own assessments of systems. RESULTS: Functionality for tracking patients and detecting those lost to follow-up is described in six HIV and MDR-TB treatment projects in Africa and Latin America. Preliminary data show benefits in tracking patients who have not been prescribed appropriate drugs, those who fail to return for follow-up, and those who do not have medications picked up for them by health care workers. There were also benefits seen in providing access to key laboratory data and in using this data to improve the timeliness and quality of care. Follow-up was typically achieved by a combination of reports from information systems along with teams of community health care workers. New technologies such as low-cost satellite Internet access, personal digital assistants, and cell phones are helping to expand the reach of these systems. CONCLUSIONS: Effective information systems in developing countries are a recent innovation but will need to play an increasing role in supporting and monitoring HIV and MDR-TB projects as they scale up from thousands to hundreds of thousands of patients. A particular focus should be placed on tracking patients from initial diagnosis to initiation of effective treatment and then monitoring them for treatment breaks or loss to follow-up. More quantitative evaluations need to be performed on the impact of electronic information systems on tracking patients.

A web-based laboratory information system to improve quality of care of tuberculosis patients in Peru: functional requirements, implementation and usage statistics.

BACKGROUND: Multi-drug resistant tuberculosis patients in resource-poor settings experience large delays in starting appropriate treatment and may not be monitored appropriately due to an overburdened laboratory system, delays in communication of results, and missing or error-prone laboratory data. The objective of this paper is to describe an electronic laboratory information system implemented to alleviate these problems and its expanding use by the Peruvian public sector, as well as examine the broader issues of implementing such systems in resource-poor settings. METHODS: A web-based laboratory information system "e-Chasqui" has been designed and implemented in Peru to improve the timeliness and quality of laboratory data. It was deployed in the national TB laboratory, two regional laboratories and twelve pilot health centres. Using needs assessment and workflow analysis tools, e-Chasqui was designed to provide for improved patient care, increased quality control, and more efficient laboratory monitoring and reporting. RESULTS: Since its full implementation in March 2006, 29,944 smear microscopy, 31,797 culture and 7,675 drug susceptibility test results have been entered. Over 99% of these results have been viewed online by the health centres. High user satisfaction and heavy use have led to the expansion of e-Chasqui to additional institutions. In total, e-Chasqui will serve a network of institutions providing medical care for over 3.1 million people. The cost to maintain this system is approximately US$0.53 per sample or 1% of the National Peruvian TB program's 2006 budget. CONCLUSION: Electronic laboratory information systems have a large potential to improve patient care and public health monitoring in resource-poor settings. Some of the challenges faced in these settings, such as lack of trained personnel, limited transportation, and large coverage areas, are obstacles that a well-designed system can overcome. e-Chasqui has the potential to provide a national TB laboratory network in Peru. Furthermore, the core functionality of e-Chasqui as been implemented in the open source medical record system OpenMRS http://www.openmrs.org for other countries to use.

Experience in implementing the OpenMRS medical record system to support HIV treatment in Rwanda.

The challenge of scaling up HIV treatment in Africa has led to a new emphasis on improving health systems in impoverished areas. One aspect of this is the development and deployment of electronic medical record systems to support HIV and TB treatment. In this paper we describe the design and implementation of a new medical record architecture to support an HIV treatment program in rural Rwanda. The architecture is called OpenMRS and it has been developed to address the problem of configuring EMR systems to suit new sites, languages and diseases. OpenMRS uses a data dictionary called the concept dictionary to represent all the possible data items that can be collected. This allows new items to be added to the system by non-programmers. In addition, there are form creation tools that use drag and drop web technologies to simplify form construction. The OpenMRS system was first implemented in Kenya in February 2006 and then in Rwanda in August 2006. The system is now functioning well and we are developing extensions to improve the support for the clinic. These include improved, easy to use reporting tools, support for additional clinical problems including nutrition and child health, better database synchronization tools, and modules to collect laboratory data and support the pharmacy. The system is also in use in South Africa and Lesotho and is being deployed in Tanzania and Uganda.

Implementing electronic medical record systems in developing countries.

The developing world faces a series of health crises including HIV/AIDS and tuberculosis that threaten the lives of millions of people. Lack of infrastructure and trained, experienced staff are considered important barriers to scaling up treatment for these diseases. In this paper we explain why information systems are important in many healthcare projects in the developing world. We discuss pilot projects demonstrating that such systems are possible and can expand to manage hundreds of thousands of patients. We also pass on the most important practical lessons in design and implementation from our experience in doing this work. Finally, we discuss the importance of collaboration between projects in the development of electronic medical record systems rather than reinventing systems in isolation, and the use of open standards and open source software.

Evaluation of a cardiac diagnostic program in a typical clinical setting.

CONTEXT: The Heart Disease Program (HDP) is a novel computerized diagnosis program incorporating a computer model of cardiovascular physiology. Physicians can enter standard clinical data and receive a differential diagnosis with explanations. OBJECTIVE: To evaluate the diagnostic performance of the HDP and its usability by physicians in a typical clinical setting. DESIGN: A prospective observational study of the HDP in use by physicians in departments of medicine and cardiology of a teaching hospital. Data came from 114 patients with a broad range of cardiac disorders, entered by six physicians. MEASUREMENTS: Sensitivity, specificity, and positive predictive value (PPV). Comprehensiveness: the proportion of final diagnoses suggested by the HDP or physicians for each case. RELEVANCE: the proportion of HDP or physicians' diagnoses that are correct. Area under the receiver operating characteristic (ROC) curve (AUC) for the HDP and the physicians. Performance was compared with a final diagnosis based on follow-up and further investigations. RESULTS: Compared with the final diagnoses, the HDP had a higher sensitivity (53.0% vs. 34.8%) and significantly higher comprehensiveness (57.2% vs. 39.5%, p < 0.0001) than the physicians. Physicians' PPV and relevance (56.2%, 56.0%) were higher than the HDP (25.4%, 28.1%). Combining the diagnoses of the physicians and the HDPs, sensitivity was 61.3% and comprehensiveness was 65.7%. These findings were significant in the two collection cohorts and for subanalysis of the most serious diagnoses. The AUCs were similar for the HDP and the physicians. CONCLUSIONS: The heart disease program has the potential to improve the differential diagnoses of physicians in a typical clinical setting.

Is it influenza or anthrax? A decision analytic approach to the treatment of patients with influenza-like illnesses.

STUDY OBJECTIVE: We analyze the risks and benefits of alternative treatment strategies for non-septic-appearing febrile patients with influenza-like illnesses and possible exposure to anthrax. METHODS: We used a decision analytic model to evaluate 6 testing and treatment strategies in an emergency department. Patients were non-septic-appearing and had influenza-like illnesses but low likelihood of exposure to anthrax. The following interventions were used: (1) no empiric antibiotics; (2) blood culture and treatment only if the result was positive; (3) rapid testing for influenza and, for those who tested negative, treatment with 60 days of ciprofloxacin; (4) a two-test strategy in which all patients were first tested for influenza; those who tested negative had a blood culture test and were treated empirically with ciprofloxacin for 3 days while waiting for blood culture results; (5) culture test for all patients and treatment with ciprofloxacin for up to 3 days while waiting for blood culture results; and (6) treatment of all patients with ciprofloxacin empirically for 60 days. Main outcome measures were deaths, complications from anthrax, adverse events from ciprofloxacin, and ciprofloxacin patient-days. RESULTS: For nonzero probabilities of anthrax, patient mortality was always lowest in the strategies in which all patients were treated empirically for anthrax either for 60 days or for 3 days pending blood culture results. These strategies, however, were associated with more morbidity (more ciprofloxacin patient-days and more antibiotic adverse events) than were strategies without empiric treatment. The numbers of adverse events and antibiotic patient-days were reduced substantially with the two-test strategy, in which patients with influenza were identified early and not treated. In general, for probabilities of anthrax equaling or exceeding 2%, treating all patients empirically for 60 days was best, but for probabilities between 0.1% and 2%, the sensitivity of blood culture for anthrax determined the optimal strategy: when the sensitivity exceeded 95%, a short course of empiric ciprofloxacin until blood culture results became available was best, but for sensitivities below 95%, more aggressive empiric antibiotics use was warranted. The proportion of patients with influenza in the community affected the choice of strategy, so that seasonal variation exists. CONCLUSION: During influenza season, our findings support rapid testing for influenza, followed by empiric treatment for anthrax pending blood culture results for those who test negative for influenza. Our results help to highlight the importance of developing rapid and sensitive tests for anthrax and of developing improved surveillance and methods to calculate the previous probability of attacks.