Novel Techniques to Assess Predictive Systems and Reduce Their Alarm Burden.

Machine prediction algorithms (e.g., binary classifiers) often are adopted on the basis of claimed performance using classic metrics such as precision and recall. However, classifier performance depends heavily upon the context (workflow) in which the classifier operates. Classic metrics do not reflect the realized performance of a predictor unless certain implicit assumptions are met, and these assumptions cannot be met in many common clinical scenarios. This often results in suboptimal implementations and in disappointment when expected outcomes are not achieved. One common failure mode for classic metrics arises when multiple predictions can be made for the same event, particularly when redundant true positive predictions produce little additional value. This describes many clinical alerting systems. We explain why classic metrics cannot correctly represent predictor performance in such contexts, and introduce an improved performance assessment technique using utility functions to score predictions based on their utility in a specific workflow context. The resulting utility metrics (u-metrics) explicitly account for the effects of temporal relationships and other sources of variability in prediction utility. Compared to traditional measures, u-metrics more accurately reflect the real-world costs and benefits of a predictor operating in a realized context. The improvement can be significant. We also describe a formal approach to snoozing, a mitigation strategy in which some predictions are suppressed to improve predictor performance by reducing false positives while retaining event capture. Snoozing is especially useful for predictors that generate interruptive alarms. U-metrics correctly measure and predict the performance benefits of snoozing, whereas traditional metrics do not.

Core content for training in venous and lymphatic medicine.

The major venous societies in the United States share a common mission to improve the standards of medical practitioners, the educational goals for teaching and training programs in venous disease, and the quality of patient care related to the treatment of venous disorders. With these important goals in mind, a task force made up of experts from the specialties of dermatology, interventional radiology, phlebology, vascular medicine, and vascular surgery was formed to develop a consensus document describing the Core Content for venous and lymphatic medicine and to develop a core educational content outline for training. This outline describes the areas of knowledge considered essential for practice in the field, which encompasses the study, diagnosis, and treatment of patients with acute and chronic venous and lymphatic disorders. The American Venous Forum and the American College of Phlebology have endorsed the Core Content.

Indistinguishable from magic: health and wellness in a future of sufficiently advanced technology.

We describe a future in which health and wellness are transformed by (1) the availability of definitive and unambiguous tests to prove or disprove each diagnosis, (2) new methods based in systems biology to help unravel the web of messages transmitted across cellular and subcellular networks, and (3) universal access to data that has been freed from data silos to produce true data liquidity for a constellation of purposes ranging from personal health management to population health research. We believe the resulting "connected health" environment will have a profound impact on every aspect of modern life.

Searching electronic health records for temporal patterns in patient histories: a case study with microsoft amalga.

As electronic health records (EHR) become more widespread, they enable clinicians and researchers to pose complex queries that can benefit immediate patient care and deepen understanding of medical treatment and outcomes. However, current query tools make complex temporal queries difficult to pose, and physicians have to rely on computer professionals to specify the queries for them. This paper describes our efforts to develop a novel query tool implemented in a large operational system at the Washington Hospital Center (Microsoft Amalga, formerly known as Azyxxi). We describe our design of the interface to specify temporal patterns and the visual presentation of results, and report on a pilot user study looking for adverse reactions following radiology studies using contrast.

A gesture-based tool for sterile browsing of radiology images.

The use of doctor-computer interaction devices in the operation room (OR) requires new modalities that support medical imaging manipulation while allowing doctors' hands to remain sterile, supporting their focus of attention, and providing fast response times. This paper presents "Gestix," a vision-based hand gesture capture and recognition system that interprets in real-time the user's gestures for navigation and manipulation of images in an electronic medical record (EMR) database. Navigation and other gestures are translated to commands based on their temporal trajectories, through video capture. "Gestix" was tested during a brain biopsy procedure. In the in vivo experiment, this interface prevented the surgeon's focus shift and change of location while achieving a rapid intuitive reaction and easy interaction. Data from two usability tests provide insights and implications regarding human-computer interaction based on nonverbal conversational modalities.

Metrics in the science of surge.

Metrics are the driver to positive change toward better patient care. However, the research into the metrics of the science of surge is incomplete, research funding is inadequate, and we lack a criterion standard metric for identifying and quantifying surge capacity. Therefore, a consensus working group was formed through a "viral invitation" process. With a combination of online discussion through a group e-mail list and in-person discussion at a breakout session of the Academic Emergency Medicine 2006 Consensus Conference, "The Science of Surge," seven consensus statements were generated. These statements emphasize the importance of funded research in the area of surge capacity metrics; the utility of an emergency medicine research registry; the need to make the data available to clinicians, administrators, public health officials, and internal and external systems; the importance of real-time data, data standards, and electronic transmission; seamless integration of data capture into the care process; the value of having data available from a single point of access through which data mining, forecasting, and modeling can be performed; and the basic necessity of a criterion standard metric for quantifying surge capacity. Further consensus work is needed to select a criterion standard metric for quantifying surge capacity. These consensus statements cover the future research needs, the infrastructure needs, and the data that are needed for a state-of-the-art approach to surge and surge capacity.

Wireless handheld computers and voluntary utilization of computerized prescribing systems in the emergency department.

Illegible or invalid hand-written prescriptions can result in avoidable medical errors. Computer-based prescribing can mitigate the problem. An observational study was performed to examine the effect of wireless handheld computers (handhelds) on voluntary utilization of computerized prescribing within an Emergency Department. Handhelds with prescription-writing software were provided to physicians and the numbers of hand-written and computer-generated prescriptions were compared before and after the introduction of the handhelds. The resulting increase in computer-based prescribing was statistically significant and was observed largely among physicians who already used desktop computers for prescribing. The study concluded that handhelds increased voluntary utilization of computerized prescribing, but that the physicians most likely to use handhelds were those who already used desktop-based prescribing.

A real-time gesture interface for hands-free control of electronic medical records.

Whether attempting to review digital radiologic images during a procedure or reviewing labs on a clinical ward, computer keyboards and mice are potential sources for contamination of clinicians during sterile and non-sterile activities related to clinical care. The authors describe and demonstrate a live system prototype for hands-free, gesture-based control of an electronic medical record (EMR) system.

Automated patient facial image capture to reduce medical error.

The authors describe their experiences creating technology to automatically capture facial images from patients during triage and registration for integration into the electronic medical record (EMR) to reduce data retrieval and data entry errors. The prototype system was tested across a variety of ethnicities with facial images captured successfully in 100% of cases with a median time to capture of 0.75 seconds.

Improving a UMLS based allergy list for use in live electronic medical record systems.

The SNOMED allergy subset available through the UMLS has a variety of deficits that are substantial barriers to use in live clinical practice. These authors describe a method of enhancing a UMLS based allergy list by combining concepts from other terminologies found within the UMLS. This method resulted in a three-fold increase in the coverage allergy list compared to the standard SNOMED allergy subset.

Use of medical robotics in biothreat situations.

SARS, Avian Flu and other infectious and potentially highly transmissible diseases are threats to the entire healthcare workforce. Complete bio-isolation or the use of biohazard suits are not practical solutions for routine day-to-day patient-doctor interactions with highly infectious patients. The authors share their initial research experiences with utilizing medical robots for teleconferencing and other clinical activities to overcome these hurdles.

Automated medical image library creation for education.

The authors describe a method to create a medical teaching library that is automatically maintained, contains tens of thousands of radiologic images and is built using existing, internal, hospital dictations, radiologic images, and an off-the-shelf commercial search engine product (Google Inc.).

Keynote address: medical informatics and emergency medicine.

A personal look at some of the developments in practical clinical informatics over the past two decades, with discussion of several successful projects, including the National Center for Emergency Medicine Informatics, the Azyxxi system, Federal Project ER One, the Institutes for Innovation in Medicine, the Medical MediaLab, Project Sentinel, and others. Lessons learned, and hints and suggestions for future developers and informaticists.

Computerized physician order entry and online decision support.

Computerized physician order entry (CPOE) and decision support systems (DSS) can reduce certain types of error but often slow clinicians and may increase other types of error. The net effect of these systems on an emergency department (ED) is unknown. The consensus participants combined published evidence with expert opinion to outline recommendations for success. These include seamless integration of CPOE and DSS into systems and workflow; ensuring access to Internet-based and other online support material in the clinical arena; designing systems specifically for the ED and measuring their impact to ensure an overall benefit; ensuring that CPOE systems provide error and interaction checking and facilitate weight- and physiology-based dosing; using interruptive alerts only for the highest-severity events; providing a simple, vendor-independent interface for institutional customization of CPOE alert thresholds; maximizing the use of automated systems and passive data capture; and ensuring the widespread availability of CPOE and DSS using secure wireless and portable technologies where appropriate. Decisions regarding CPOE and DSS in the ED should be guided by the ED chair or designee. Much of what is believed to be true regarding CPOE and DSS has not been adequately studied. Additional CPOE and DSS research is needed quickly, and this research should receive funding priority. DSS and CPOE hold great promise to improve patient care, but not all systems are equal. Evidence must guide these efforts, and the measured outcomes must consider the many factors of quality care.

Clinical information systems: instant ubiquitous clinical data for error reduction and improved clinical outcomes.

Immediate access to existing clinical information is inadequate in current medical practice; lack of existing information causes or contributes to many classes of medical error, including diagnostic and treatment error. A review of the literature finds ample evidence to support a description of the problems caused by data that are missing or unavailable but little evidence to support one proposed solution over another. A primary recommendation of the Consensus Committee is that hospitals and departments should adopt systems that provide fast, ubiquitous, and unified access to all types of existing data. Additional recommendations cover a variety of related functions and operational concepts, from backups and biosurveillance to speed, training, and usability.

The Frontlines of Medicine Project: a proposal for the standardized communication of emergency department data for public health uses including syndromic surveillance for biological and chemical terrorism.

The Frontlines of Medicine Project is a collaborative effort of emergency medicine (including emergency medical services and clinical toxicology), public health, emergency government, law enforcement, and informatics. This collaboration proposes to develop a nonproprietary, "open systems" approach for reporting emergency department patient data. The common element is a standard approach to sending messages from individual EDs to regional oversight entities that could then analyze the data received. ED encounter data could be used for various public health initiatives, including syndromic surveillance for chemical and biological terrorism. The interlinking of these regional systems could also permit public health surveillance at a national level based on ED patient encounter data. Advancements in the Internet and Web-based technologies could allow the deployment of these standardized tools in a rapid time frame.

Venous thrombosis.

Preview The list of recognized risk factors for deep venous thrombosis and pulmonary embolism is formidable. Classic findings of edema, warmth, erythema, and tenderness are often absent. A clinical impression of deep venous thrombosis is correct only 50% of the time and must be confirmed with imaging studies. Management includes thrombolysis, surgical thrombectomy and, in some cases, lifelong use of anticoagulants.