Clinical inertia in the management of Type 2 diabetes metabolic risk factors.

AIMS: Delays in the initiation and intensification of medical therapy may be one reason patients with diabetes do not reach evidence-based goals for metabolic control. We assessed intensification of medical therapy over time, comparing the management of hyperglycaemia, hypertension, and hyperlipidaemia. METHODS: Prospective cohort study of 598 adults with Type 2 diabetes receiving primary care in an academic medical centre from May 1997 to April 1999. We assessed whether patients failing to achieve standard treatment goals for haemoglobin A1c (HbA1c), systolic blood pressure (SBP), or low density lipoprotein (LDL) cholesterol when last measured during 12 months (Year 1, 5/97-4/98) had increases in their corresponding medical regimen during the following 12 months (Year 2, 5/98-4/99). RESULTS: Among untreated patients in Year 1, seven of 12 (58%) of those above goal for HbA1c were initiated on medical therapy in Year 2, compared with 16 of 48 (34%) above SBP goal (P=0.02) and 26 of 115 (23%) above LDL cholesterol goal (P=0.02). Among patients on therapy and above goal, 124 of 244 (51%) patients with elevated HbA1c had their regimen increased in Year 2, compared with 85 of 282 (30%) with elevated SBP (P<0.001) and 22 of 79 (30%) with elevated LDL cholesterol (P<0.001). From Year 1 to Year 2 there was a decline in the overall proportion of patients above goal for LDL cholesterol (from 58% to 45%, P=0.002) but not for HbA1c or blood pressure. CONCLUSIONS: Greater initiation and intensification of pharmaceutical therapy, particularly for elevated blood pressure or cholesterol, may represent a specific opportunity to improve metabolic control in Type 2 diabetes.

An XML-based format for guideline interchange and execution.

In building a general purpose guideline system based on GLIF--the GuideLine Interchange Format, we encountered limitations in the GLIF specification. These limitations, while not so apparent in the static version of guideline content, became readily so in the context of real world implementation, and pertain not only to GLIF-based systems, but generally as well. These limitations can be described as being in one of five categories. In this paper, we describe each of these categories in detail, and show how an execution environment based on XML data structures addresses these concerns.

Experience with an electronic health record for a homeless population.

A computerized electronic medical record (EMR) system using client-server architecture was designed and implemented by the Laboratory of Computer Science for use by the Boston Health Care for the Homeless Program (BHCHP) to meet the unique medical record needs of the homeless. For the past three years, this EMR has been used to assist providers in the delivery of health care to the homeless population of Boston. As the BHCHP has grown and technology improved, it is important to review what features of the EMR work, and to investigate what improvements can be made for the better delivery of care to the homeless, especially as we approach the next century.

Optimizing healthcare research data warehouse design through past COSTAR query analysis.

Over the past two years we have reviewed and implemented the specifications for a large relational database (a data warehouse) to find research cohorts from data similar to that contained within the clinical COSTAR database at the Massachusetts General Hospital. A review of 16 years of COSTAR research queries was conducted to determine the most common search strategies. These search strategies are relevant to the general research community, because they use the Medical Query Language (MQL) developed for the COSTAR M database which is extremely flexible (much more so than SQL) and allows searches by coded fields, text reports, and laboratory values in a completely ad hoc fashion. By reviewing these search strategies, we were able to obtain user specifications for a research oriented healthcare data warehouse that could support 90% of the queries. The data warehouse was implemented in a relational database using the star schema, allowing for highly optimized analytical processing. This allowed queries that performed slowly in the M database to be performed very rapidly in the relational database. It also allowed the data warehouse to scale effectively.

Components of the optimal ambulatory care computing environment.

We present here a framework of core components of an ambulatory care computing environment, based on clinical and functional needs and workflow scenarios. We have established this framework through the use of two study devices: a vision of the clinical office of the future, and a survey of possible computer applications, both designed to help clinicians and practice directors communicate their information needs to systems designers. Clinicians prioritize applications based on strategic and practice goals: support for clinical users' workflow, improved quality of care, reduced cost of care, and the ability to measure performance and status. By reorganizing the needed functionality from a clinical viewpoint into a technical viewpoint, we are able to identify core information components for systems design. Based on this analysis, information needs in the ambulatory environment can be divided into five primary functions: patient data retrieval, documentation, communication, knowledge resources, and aggregate reporting. Three other fundamental processes--knowledge-based interventions, information integration, and confidentiality--run through all of these front-line functions. Component applications and data structures built with this framework in mind will afford a maximum combination of functionality and flexibility to handle future changes in the clinical environment.

Component architecture for web based EMR applications.

The World Wide Web provides the means for the collation and display of disseminated clinical information of use to the healthcare provider. However, the heterogeneous nature of clinical data storage and formats makes it very difficult for the physician to use one consistent client application to view and manipulate information. Similarly, developers are faced with a multitude of possibilities when creating interfaces for their users. A single patients records may be distributed over a number of different record keeping systems, and/or a physician may see patients whose individual records are stored at different sites. Our goal is to provide the healthcare worker with a consistent application interface independent of the parent database and at the same time allow developers the opportunity to customize the GUI in a well controlled, stable application environment.

A software architecture to support a large-scale, multi-tier clinical information system.

A robust software architecture is necessary to support a large-scale multi-tier clinical information system. This paper describes our mechanism for enterprise distribution of applications and support files, the consolidation of data-access functions and system utilities stored on the data access tier, and an application framework which implements a coherent clinical computing environment. The software architecture and systems described in this paper have been robust through pilot testing of our applications at Massachusetts General Hospital.

An XML portable chart format.

The clinical chart remains the fundamental record of outpatient clinical care. As this information migrates to electronic form, there is an opportunity to create standard formats for transmitting these charts. This paper describes work toward a Portable Chart Format (PCF) that can represent the relevant aspects of an outpatient chart. The main goal of the format is to provide a packaging medium for outpatient clinical charts in a transfer of care scenario. A secondary goal is to support the aggregation of comparable clinical data for outcomes analysis. The syntax used for PCF is Extended Markup Language (XML), a W3C standard. The structure of the PCF is based on a clinically relevant view of the data. The data definitions and nomenclature used are based primarily on existing clinical standards.

Maintaining the confidentiality of medical records shared over the Internet and the World Wide Web.

The Boston Electronic Medical Record Collaborative is working to develop a system that will use the World Wide Web to transfer computer-based patient information to clinicians in emergency departments. Maintaining adequate confidentiality of these records while still facilitating patient care is paramount to this effort. This paper describes an explicit protocol that would make it possible to electronically identify patients and providers, secure permission for release of records, and track information that is transmitted. It is hoped that other, similar efforts now underway will be able to use and build on this model. Comment on this proposal is invited from all parties with an interest in confidentiality. The system will be used only with "scrubbed" data-data from which all identifiers have been removed-until it is generally agreed that the confidentiality methods proposed here are appropriate and sufficient.

Maintaining the integrity of a Web-based medical vocabulary glossary.

Medical vocabulary databases are vital components of electronic medical record (EMR) systems. While their performance and efficiency has been extensively explored by many authors, few have dealt with the maintenance of their semantic integrity. Clinicians' preference for an optimistic system has introduced a need for monitoring and filtering proposed additions to the vocabulary tables. We propose the use of batch processing and memo-posting as means of implementing a World-Wide-Web-based Controlled Vocabulary Glossary as a monitored optimistic system.

Design considerations in migrating an obstetrics clinical record to the Web.

Recently the American College of Obstetricians and Gynecologists (ACOG) embarked on an effort to promote the development of nationally networked obstetrical records. The Laboratory of Computer Science (LCS) is collaborating with them to help achieve this goal through the development of a web-based prototype of an electronic medical record (EMR) which would allow the entry and display of typical clinical information for the obstetric patient. The process of porting a stand alone application to the web environment necessitated the development of a robust software scheme that could exploit the strengths of Web-based technologies and avoid some of the drawbacks inherent in a stateless environment.

Preserving context in a multi-tasking clinical environment: a pilot implementation.

The Partners Clinical Application Suite (CAS) is a multi-tasking software architecture that facilitates the development, deployment, and use of advanced clinical information management applications. This paper describes 1) a software shell in which clinical applications run; 2) an application programming interface (API); and 3) development of a set of "Look & Feel" guidelines. Through its emphasis on support for multi-tasking and application interoperability, CAS facilitates preservation of the user's context.

A component-based, distributed object services architecture for a clinical workstation.

Attention to an architectural framework in the development of clinical applications can promote reusability of both legacy systems as well as newly designed software. We describe one approach to an architecture for a clinical workstation application which is based on a critical middle tier of distributed object-oriented services. This tier of network-based services provides flexibility in the creation of both the user interface and the database tiers. We developed a clinical workstation for ambulatory care using this architecture, defining a number of core services including those for vocabulary, patient index, documents, charting, security, and encounter management. These services can be implemented through proprietary or more standard distributed object interfaces such as CORBA and OLE. Services are accessed over the network by a collection of user interface components which can be mixed and matched to form a variety of interface styles. These services have also been reused with several applications based on World Wide Web browser interfaces.

Client-server, distributed database strategies in a health-care record system for a homeless population.

OBJECTIVE: To design and develop a computer-based health-care record system to address the needs of the patients and providers of a homeless population. DESIGN: A computer-based health-care record system being developed for Boston's Healthcare for the Homeless Program (BHCHP) uses client-server technology and distributed database strategies to provide a common medical record for this transient population. The differing information requirements of physicians, nurses, and social workers are specifically addressed in the graphic application interface to facilitate an integrated approach to health care. This computer-based record system is designed for remote and portable use to integrate smoothly into the daily practice of providers of care to the homeless. The system uses remote networking technology and regular phone lines to support multiple concurrent users at remote sites of care. RESULTS: A stand-alone, pilot system is in operation at the BHCHP medical respite unit. Information on 129 patient encounters from 37 unique sites has been entered. A full client-server system has been designed. Benchmarks show that while the relative performance of a communication link based upon a phone line is 0.07 to 0.15 that of a local area network, optimization permits adequate response. CONCLUSION: Medical records access in a transient population poses special problems. Use of client-server and distributed database strategies can provide a technical foundation that provides a secure, reliable, and accessible computer-based medical record in this environment.

Client-server, distributed database strategies in a healthcare record system for a homeless population.

A computer-based healthcare record system being developed for Boston's Healthcare for the Homeless Program (BHCHP) uses client-server and distributed database technologies to enhance the delivery of healthcare to patients of this unusual population. The needs of physicians, nurses and social workers are specifically addressed in the application interface so that an integrated approach to healthcare for this population can be facilitated. These patients and their providers have unique medical information needs that are supported by both database and applications technology. To integrate the information capabilities with the actual practice of providers of care to the homeless, this computer-based record system is designed for remote and portable use over regular phone lines. An initial standalone system is being used at one major BHCHP site of care. This project describes methods for creating a secure, accessible, and scalable computer-based medical record using client-server, distributed database design.