The electronic medical record. A randomized trial of its impact on primary care physicians' initial management of major depression [corrected].

BACKGROUND: Inadequate treatments are reported for depressed patients cared for by primary care physicians (PCPs). Providing feedback and evidence-based treatment recommendations for depression to PCPs via electronic medical record improves the quality of interventions. METHODS: Patients presenting to an urban academically affiliated primary care practice were screened for major depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD). During 20-month period, 212 patients met protocol-eligibility criteria and completed a baseline interview. They were cared for by 16 board-certified internists, who were electronically informed of their patients' diagnoses, and randomized to 1 of 3 methods of exposure to guideline-based advice for treating depression (active, passive, and usual care). Ensuing treatment patterns were assessed by medical chart review and by patient self-report at baseline and 3 months. RESULTS: Median time for PCP response to the electronic message regarding the patient's depression diagnosis was 1 day (range, 1-95 days). Three days after notification, 120 (65%) of 186 PCP responses indicated agreement with the diagnosis, 24 (13%) indicated disagreement, and 42 (23%) indicated uncertainty. Primary care physicians who agreed with the diagnoses sooner were more likely to make a medical chart notation of depression, begin antidepressant medication therapy, or refer to a mental health specialist (P<.001). There were no differences in the agreement rate or treatments provided across guideline exposure conditions. CONCLUSIONS: Electronic feedback of the diagnosis of major depression can affect PCP initial management of the disorder. Further study is necessary to determine whether this strategy, combined with delivery of treatment recommendations, can improve clinical outcomes in routine practice.

Evaluation of a filmless radiology pilot--a preliminary report.

The development of the Multimedia Electronic Medical Record System (MEMRS) promises new opportunities to significantly reduce the routine use of film as the medium for viewing radiological medical images. The effect of this change to digital media on physician workflow and the perceived value and utility of medical images is an area of ongoing investigation. In this study we examined oncology clinicians use of medical images in a MEMRS. We conducted observational studies of clinicians during a filmless radiology pilot study in which a filmless environment was simulated but the actual film was available on request. This observational study was the first step in a comprehensive evaluation designed to elucidate the issues surrounding the implementation of a filmless radiology environment. We identified and examined several of these issues, including physician concern regarding the utility of digital images for clinical use and comparison with film, the need to address the effects of image compression with clinicians, and the workflow changes necessary to incorporate digital image use into a clinical practice.

Defining the role of anatomic pathology images in the multimedia electronic medical record--a preliminary report.

The development of the Multimedia Electronic Medical Record System (MEMRS) offers new opportunities for integrating medical imaging data with text-based clinical data. The effective integration of pathology images into the patient's medical record poses some significant technical and organizational challenges. Before these challenges can be met, it is imperative that we investigate the value and utility of providing these images to clinicians. In this study we examined attitudes towards use of pathology images in Image Engine, a MEMRS under development at the University of Pittsburgh Cancer Institute (UPCI). We conducted semi-structured standardized interviews with a cohort of practicing oncologists, all of whom had significant experience with Image Engine. This study is a first step towards elucidating the potential barriers, uses, and value of anatomic pathology images in the MEMRS.

Transforming the cancer center in the 21st century.

Academic cancer centers will be hit, simultaneously, by all three of the technology tidal waves outlined above within the next five years. In preparing for this impact one should note the central role that Internet technologies will play in providing solutions in all three areas. In addition, as the volume and size of data objects increases dramatically, having an adequate networking infrastructure in place will be crucial. So what do we do now to prepare for the future? The following five steps are suggested: (1) Establish an oncology informatics group within the cancer center to provide the necessary expertise and begin the planning process. (2) Begin implementing a secure intranet based on standard Internet technologies. (3) Work with the host medical center and external agencies to determine who will pay for and implement a high-bandwidth networking infrastructure. (4) Recruit a bioinformatician who can help implement technologies to take advantage of the genomics data wave when it hits. (5) Ensure that the cancer center's EMR system can support cancer protocol data and facilitate the retrieval and delivery of the complex digital imaging data that are in our future.

Multimedia electronic medical record systems.

A wide range of imaging technologies are becoming increasingly important to the practice of medicine. In addition, many medical specialties are highly visual, independent of their use of new imaging modalities. Because today's medical record contains text, images, and physiologic signals, it is inherently multimedia in nature. However, most electronic medical record systems handle only the textual portion of the patient record, resulting in a fragmentation of the database that physicians need to make timely, effective clinical decisions. Advances in database-, storage-, data-compression, and networking technologies will facilitate the development of multimedia electronic medical record systems for the 21st century. These systems will become widely used over the next decade, and in addition to enhancing patient care, will also present new opportunities for using clinical imaging data for biomedical research and education.

The electronic medical record: its role in disseminating depression guidelines in primary care practice.

OBJECTIVE: Using the Agency for Health Care Policy and Research Depression Guideline Panel's recommendations as its focus, this article describes a step-by-step approach for disseminating a paper-based depression guideline to primary care physicians via a commercially available electronic medical record (EMR) system. METHOD: Description of the author's approach to disseminate an evidence-based depression treatment guideline to a group of primary care physicians using a commercially available EMR system and to evaluate the results. RESULTS: We review clinical considerations and practical barriers faced in this process with the expectation that our experiences can guide others attempting to disseminate psychiatric treatment guideline via EMR systems. CONCLUSIONS: The EMR offers critical efficiencies in disseminating state-of-the-art clinical practice guidelines and in directing the primary care physicians' use of them. Still, well-designed, randomized controlled trials are necessary to demonstrate their effectiveness at enhancing patient outcomes for major depression in primary care settings.

Automated semantic indexing of imaging reports to support retrieval of medical images in the multimedia electronic medical record.

This paper describes preliminary work evaluating automated semantic indexing of radiology imaging reports to represent images stored in the Image Engine multimedia medical record system at the University of Pittsburgh Medical Center. The authors used the SAPHIRE indexing system to automatically identify important biomedical concepts within radiology reports and represent these concepts with terms from the 1998 edition of the U.S. National Library of Medicine's Unified Medical Language System (UMLS) Metathesaurus. This automated UMLS indexing was then compared with manual UMLS indexing of the same reports. Human indexing identified appropriate UMLS Metathesaurus descriptors for 81% of the important biomedical concepts contained in the report set. SAPHIRE automatically identified UMLS Metathesaurus descriptors for 64% of the important biomedical concepts contained in the report set. The overall conclusions of this pilot study were that the UMLS metathesaurus provided adequate coverage of the majority of the important concepts contained within the radiology report test set and that SAPHIRE could automatically identify and translate almost two thirds of these concepts into appropriate UMLS descriptors. Further work is required to improve both the recall and precision of this automated concept extraction process.

Information needs research in the era of the digital medical library.

The rapid adoption of Internet-accessible information resources by the clinical community, has resulted in an exponential growth in the variety and type of clinical information resources along with an increasing diversity of information technologies to deliver clinical information. To date, little formal work has been done to investigate the significance of new information technologies such as Internet-based digital libraries and multimedia record systems on clinical information need or information seeking behavior. In the work described in this paper, we highlight some results from our recent multimethod research design and investigation of the information-seeking behavior of Pittsburgh area medical oncologists to argue for the use of a multimethod research design as an essential component of any investigation of clinical information need and information-seeking behavior in the era of the digital medical library.

Towards knowledge-based retrieval of medical images. The role of semantic indexing, image content representation and knowledge-based retrieval.

Medicine is increasingly image-intensive. The central importance of imaging technologies such as computerized tomography and magnetic resonance imaging in clinical decision making, combined with the trend to store many "traditional" clinical images such as conventional radiographs, microscopic pathology and dermatology images in digital format present both challenges and an opportunities for the designers of clinical information systems. The emergence of Multimedia Electronic Medical Record Systems (MEMRS), architectures that integrate medical images with text-based clinical data, will further hasten this trend. The development of these systems, storing a large and diverse set of medical images, suggests that in the future MEMRS will become important digital libraries supporting patient care, research and education. The representation and retrieval of clinical images within these systems is problematic as conventional database architectures and information retrieval models have, until recently, focused largely on text-based data. Medical imaging data differs in many ways from text-based medical data but perhaps the most important difference is that the information contained within imaging data is fundamentally knowledge-based. New representational and retrieval models for clinical images will be required to address this issue. Within the Image Engine multimedia medical record system project at the University of Pittsburgh we are evolving an approach to representation and retrieval of medical images which combines semantic indexing using the UMLS Metathesuarus, image content-based representation and knowledge-based image analysis.

WebReport: a World Wide Web based clinical multimedia reporting system.

This paper describes WebReport, a World Wide Web (WWW) client for the Image Engine multimedia clinical information system under development at the University of Pittsburgh. WebReport uses advanced HTML features such as frames, forms, tables and inline JPEG image display to provide an easy to use system for retrieving and viewing diagnostic images and reports generated by clinical procedures such as gastrointestinal endoscopy, radiology and surgical pathology. WebReport implements a number of WWW client-side features, such as HTML forms data entry verification and makes extensive use of the JavaScript programming language. The WebReport system uses a number of approaches for ensuring the confidentiality and security of patient data transmitted over the InterNet.

The World Wide Web: a review of an emerging internet-based technology for the distribution of biomedical information.

The Internet is rapidly evolving from a resource used primarily by the research community to a true global information network offering a wide range of databases and services. This evolution presents many opportunities for improved access to biomedical information, but Internet-based resources have often been difficult for the non-expert to develop and use. The World Wide Web (WWW) supports an inexpensive, easy-to-use, cross-platform, graphic interface to the Internet that may radically alter the way we retrieve and disseminate medical data. This paper summarizes the Internet and hypertext origins of the WWW, reviews WWW-specific technologies, and describes current and future applications of this technology in medicine and medical informatics. The paper also includes an appendix of useful biomedical WWW servers.

Image engine: an integrated multimedia clinical information system.

Image Engine is a microcomputer-based system for the integration, storage, retrieval, and sharing of digitized clinical images. The system seeks to address the problem of integrating a wide range of clinically important images with the text-based electronic patient record. Rather than create a single, integrated database system for all clinical data, we are developing a separate image database system that creates real-time, dynamic links to other network-based clinical databases. To the user, this system will present an integrated multimedia representation of the patient record, providing access to both the image and text-based data required for effective clinical decision making.

Building a medical multimedia database system to integrate clinical information: an application of high-performance computing and communications technology.

The rapid growth of diagnostic-imaging technologies over the past two decades has dramatically increased the amount of nontextual data generated in clinical medicine. The architecture of traditional, text-oriented, clinical information systems has made the integration of digitized clinical images with the patient record problematic. Systems for the classification, retrieval, and integration of clinical images are in their infancy. Recent advances in high-performance computing, imaging, and networking technology now make it technologically and economically feasible to develop an integrated, multimedia, electronic patient record. As part of The National Library of Medicine's Biomedical Applications of High-Performance Computing and Communications program, we plan to develop Image Engine, a prototype microcomputer-based system for the storage, retrieval, integration, and sharing of a wide range of clinically important digital images. Images stored in the Image Engine database will be indexed and organized using the Unified Medical Language System Metathesaurus and will be dynamically linked to data in a text-based, clinical information system. We will evaluate Image Engine by initially implementing it in three clinical domains (oncology, gastroenterology, and clinical pathology) at the University of Pittsburgh Medical Center.

Using agent-based technology to create a cost effective, integrated, multimedia view of the electronic medical record.

Image Engine is multi-user, client-server database for the storage, retrieval and sharing of a wide range of digitized biomedical images under development at the University of Pittsburgh. This paper provides an overview of the system and describes the use of agent-based technology to integrate clinical information from the Image Engine database and the MARS clinical information system at the University of Pittsburgh Medical Center. Agent-mediated links provide a mechanism for combining clinical data from multiple databases to create a unified, multimedia view of the electronic medical record.

Understanding and using the medical subject headings (MeSH) vocabulary to perform literature searches.

The United States National Library of Medicine's (NLM) MEDLINE database is the largest and most widely used medical bibliographic database. MEDLINE is manually indexed with NLM's Medical Subject Headings (MeSH) vocabulary. Using MeSH, a searcher can potentially create powerful and unambiguous MEDLINE queries. This article reviews the structure and use of MeSH, directed toward the nonexpert, and outlines how MeSH may help resolve a number of common difficulties encountered when searching MEDLINE. The increasing importance of the MEDLINE database as an information resource and the trend toward individuals performing their own bibliographic searches makes it crucial that health care professionals become familiar with MeSH.

Image Engine: an object-oriented multimedia database for storing, retrieving and sharing medical images and text.

This paper describes Image Engine, an object-oriented, microcomputer-based, multimedia database designed to facilitate the storage and retrieval of digitized biomedical still images, video, and text using inexpensive desktop computers. The current prototype runs on Apple Macintosh computers and allows network database access via peer to peer file sharing protocols. Image Engine supports both free text and controlled vocabulary indexing of multimedia objects. The latter is implemented using the TView thesaurus model developed by the author. The current prototype of Image Engine uses the National Library of Medicine's Medical Subject Headings (MeSH) vocabulary (with UMLS Meta-1 extensions) as its indexing thesaurus.

What might echography learn from image science?

We review the current state of knowledge of the processes by which the information content of ultrasonic pulse-echo images is transferred to an observer, to the point of contributing to diagnostic judgments. As systematic knowledge in this specific field is rather sparse, we present relevant information and techniques derived from other areas of image science, both medical and otherwise. Quantitative measures both of the information content of ultrasonic and other images and of their characteristic noise content are first considered. An account is then given of the relevant aspects of human visual psychophysics, with particular reference to perception of contrast and detail, image texture, movement and colour, again with emphasis on documenting quantitative aspects of such behaviour. Against this background, we consider the efficiency, in current practice, of image information transfer to a human observer, how and to what extent this could be improved by changes in practice and, in particular, in what situations substantial innovations in machine processing of image data would be expected to improve human performance. It is suggested that several problems in the field may provide a worthwhile and challenging scope for future research.

Bases farmacológicas para o uso de éter venoso em anestesia / Pharmacological basis of intravenous diethyl ether anesthesia

Apresentam-se as bases farmacocinéticas para o emprego do éter a 5% em soluçäo de glicose por via venosa. Descrevem-se os princípios para os cálculos das quantidades a serem administradas, de acordo com os princípios expostos por Brody e desenvolvidos por Lowe para a anestesia quantitativa. A técnica preconizada é descrita com detalhes, quando se utiliza ventilaçäo com oxigênio puro e com misturas de óxido nitroso. As vantagens e as desvantagens säo descritas, ressaltando-se a segurança associada ao baixo custo de sua aplicaçäo