Micro-mainframe-link Personal Clinical Research System

We constructed a micro-mainframe-link clinical research system for personal use (Personal Clinical Research System). This system was developed with both a mainframe computer and a personal computer (PC). The prepared programs included a database manager (on the mainframe computer), a user interface program (on the PC), and a communication control program that connected the mainframe computer with the PC. The database on the mainframe computer was constructed by two methods. The first method was to transmit data from the PC to the mainframe computer. The second method was to extract data from the patient information database. Using this system, a physician is able to construct a personal research database that contains interesting data for the physician. In addition, the physician is able to accumulate data on a special field using this system. A discharge summary system is now in operation as an example of this system.     

Development of a regional computerized cancer registry and its impact on medical care

The Brockton Hospital Cancer Registry Program was developed to answer the data needs of the Southeastern Massachusetts region. Expansion of the computer system resulted in a data base that impacts in five areas of medical care. Registry data have been used to determine worthwhile screening sites, help institute new treaments, analyze patient survival, aid in patient follow-up, and upgrade hospital cancer programs. The extent of this impact and the usefulness of the registry in the region is discussed.     

Medical informatics: An emerging medical discipline

The use of computer technology in medicine is no longer the domain of only a few “gadget” happy high-tech aficionados. The rapid pace of medical progress and the increasing demands on physicians' time mandate that mechanisms be developed to deliver the tools of contemporary information management directly into the hands ofall practicing physicians. It is with this intent that the Council on Long-range Planning and Development and the Council on Scientific Affairs of the American Medical Association have developed an informational report on Medical Informatics. The technology for producing information about medicine and patients is well into the information age. However, the technology for managing this information has not kept up, at least to the extent of being available in medical facilities where it is needed. Most users of medical information, physicians included, have not crossed the threshold into the electronic/computer era of information acquisition, distribution, and assimilation. The continuing development of the physician as computer user will create a more efficient work environment for the physician while at the same time improving patient care.     

The role of health services research in the Veterans Administration-and beyond

The papers presented at the conference are summarized and the critical points of each are highlighted. There appears to be a real role for health services research in the Veterans Administration health care system, and it can be used to carry out the threefold task of learning what is now being done in the system, what has been achieved, and what needs to be done. The task is difficult but the VA and health services researchers have the skill, dedication, and resources to meet the challenge.     

AUTRES—The Johns Hopkins Hospital automated resume

The Johns Hopkins Hospital has developed AUTRES, an electronic discharge summary. This computer generated report was designed to provide improved continuity in the care of patients by offering a legible, standardized summary of the events of hospitalization. It can be sent by mail, FAX, or electronically (computer-to-computer) to the next care giver who will see the patient. It is available from any network attached terminal at the hospital and School of Medicine to support re-admission to the hospital, treatment in the emergency room, or outpatient visits. AUTRES first ran in fully supported production serving the Department of Medicine in 1988. Re-engineered to take advantage of cooperative processing, it has been implemented in Neurology, Internal Medicine, Obstetrics and Gynecology and Pediatrics, with plans for phased installation in the remaining clinical departments of The Johns Hopkins Hospital.     

Predicting the outcome of renal transplantation

Objective

Renal transplantation has dramatically improved the survival rate of hemodialysis patients. However, with a growing proportion of marginal organs and improved immunosuppression, it is necessary to verify that the established allocation system, mostly based on human leukocyte antigen matching, still meets today''s needs. The authors turn to machine-learning techniques to predict, from donor–recipient data, the estimated glomerular filtration rate (eGFR) of the recipient 1 year after transplantation.

Design

The patient''s eGFR was predicted using donor–recipient characteristics available at the time of transplantation. Donors'' data were obtained from Eurotransplant''s database, while recipients'' details were retrieved from Charité Campus Virchow-Klinikum''s database. A total of 707 renal transplantations from cadaveric donors were included.

Measurements

Two separate datasets were created, taking features with <10% missing values for one and <50% missing values for the other. Four established regressors were run on both datasets, with and without feature selection.

Results

The authors obtained a Pearson correlation coefficient between predicted and real eGFR (COR) of 0.48. The best model for the dataset was a Gaussian support vector machine with recursive feature elimination on the more inclusive dataset. All results are available at http://transplant.molgen.mpg.de/.

Limitations

For now, missing values in the data must be predicted and filled in. The performance is not as high as hoped, but the dataset seems to be the main cause.

Conclusions

Predicting the outcome is possible with the dataset at hand (COR=0.48). Valuable features include age and creatinine levels of the donor, as well as sex and weight of the recipient.     

A distributed approach to integrated inquiry and display for radiology

Picture archive and communications (PACS) systems should be flexible and modular in design so that new advances in storage, computation, and display technology can be introduced into the system without a significant redesign of existing software. The acquisition, storage, and management of radiologic images must be carefully integrated with a radiology information system. Our architecture is based on a four-level data model: (1) patient information, (2) examination information and reports, (3) image information, and (4) instances of images. The PACS being developed at the Mallinckrodt Institute of Radiology within the Electronic Radiology Laboratory consists of three primary components: application clients, database servers and image servers. One type of application client is an image-capable workstation that supports a radiology image viewing application. The application client queries the database server for information regarding patient and examination data in response to user-level requests. The database server responds to the request by retrieving the appropriate patient demographics and examination information, along with a pointer to the image/instance data from a central database. The client then uses the image data pointer to query the image server for the actual pixel data. The image server responds by transmitting the pixel data to the requesting application client or a designated auxiliary display device. Other clients act as image data acquisition nodes. Queries to the database servers are made via a library of callable subroutines. Software integrity is maintained throughout the system by dynamically loading software from a code-control database. Inquiry and display transactions, supported on a local-area network (Ethernet), have been measured and analyzed. Results and observations are presented.     

Prescription: Office automation

The mission statement of Minneapolis Children's Medical Center reads, in part, “Mindful of the unique characteristics of children, MCMC's missions is to provide a team of health care professionals attuned to the special needs of the total child, at all ages from prenatal through adolescent, in a uniquely designed facility.” Therefore an “open” professional staff, rather than a medical staff, was established consisting of physicians, dentists, and other health professionals with advanced degrees at the master's level or above, including, but not limited to, psychologists, social workers, clinical nurse specialists, chaplains, audiologists, and speech pathologists. This professional staff has grown to 650 members, extremely large for a 122-bed hospital. The professional staff office needed help in managing the volume of information associated with this large staff. To meet that need, in addition to the needs of other hospital areas, MCMC's administration made the decision to purchase office automation equipment and established a committee of hospital-wide users, rather than managerial staff, to survey their own needs, select vendors, and make the final recommendation. The word-processing system selected now maintains 650 physician profiles, each with 44 variables. Whereas prior to automation 25 separate lists needed to be updated each time a professional staff member was either added or deleted, now only individual physician profiles need to be adjusted. Programs were then designed to automate the many reports that must be done. In this paper we propose to describe this selection process and relate how the system developed has streamlined and simplified the work of the professional staff office to enable it to increase its output by over 300% without adding staff.     

An expert system for determining medicaid eligibility

The eligibility requirements for AFDC Medicaid are so extensive and complicated that most health care providers do not attempt to ascertain whether or not a particular patient is eligible for the program, even when no other source of payment is available. This results in lost revenue for health service providers nationwide amounting to hundreds of millions of dollars per year. Computer technology, in the form of expert systems, offers an opportunity to rationalize the Medicaid eligibility determination process and to do real-time assessment of patient eligibility. This article presents an expert system called MEDELEX (MEdicaidELigibilityEXpert) for determining Medicaid eligibility. The program (when run on an 8 MHz MS-DOS microcomputer with at least 640 KB of RAM) requires about 20 min for data entry and 5 sec for the actual eligibility determination. The expert system was written in Prolog and has been designed in such a way that it can be readily modified to take into account the state-to-state variability in eligibility requirements for AFDC Medicaid.     

Legal constraints and alternatives in the Veterans Administration

The Veterans Administration is a federal system that has functioned, so far, independently of state and local laws and rules. The system has proven flexible, however, as it has adjusted to meet needs perceived within its organization where legal justification has been found. The impact of the overall health care system in the United States is beginning to be felt within the Veterans Administration as the possibility of national health insurance implementation may greatly affect the number and kinds of patients seen in the hospitals. The response of the Veterans Administration system will have to be within its legal framework and an understanding of the relationship between the actual operation of the system and the law will be necessary. More and better understanding of the practical impact of external programs such as comprehensive health planning, manpower training and licensing laws will be necessary for the Veterans Administration to successfully adjust within the United States' health care framework.     

Health services research in alcoholism

Alcoholism has become an important health care problem for the United States and the VA medical care system. The percentage of inpatients in Veterans Administration hospitals with a diagnosis of alcoholism rose from 13.0% in 1970 to a high of 15.6% in 1977. Health services research work in alcoholism has generally fallen into four major areas: community diagnosis; utilization of services by alcoholics; the effectiveness, efficiency, and quality of services; and the organization of information systems and their applicability to alcoholism. Obstacles to research include a poor understanding of the prevalence of the disease among the veteran's population, but the system offers many more opportunities than obstacles. A new information system. SATAR (Substance Abuse Treatment Automated Records), offers a chance for large-scale investigation of the problem of alcoholism among VA patients when combined with other information systems and allows for special comparisons through its large, integrated network of hospitals and clinics.     

The use of X-terminals as clinical workstations

The Medical Computer Facility at the Fox Chase Cancer Center has installed X-terminals in patient examination rooms and at nursing stations for clinical data acess by physicians and nurses. The X-terminals are connected to UNIX operating system RISC processors via Ethernet. The RISC processors communicate with databases on a minicomputer cluster. Simultaneous presentation of textual (e.g., pathology and radiology reports) and graphical (e.g., clinical laboratory results) clinical data is provided under X-Windows. CT and MRI images can also be displayed in windows. Our experiences implementing X-terminal clinical workstations in a production environment will be discussed.     

Computer support for clinical and ancillary support areas

Military medicine is aggressively meeting the need for enhanced information flow and improved efficiency in the delivery of health care by implementing automated systems. A Department of Defense (DOD) Agency, the Tri-Service Medical Information Systems (TRIMIS) Program office, is centrally procuring automated data processing to support clinical and patient appointment activities within the DOD health care system of 165 hospitals and 287 clinics. The procured systems are then implemented with the assistance of the military departments. Systems are now supporting cardiology, pharmacy, radiology, clinical laboratory, and patient appointment and scheduling. Capabilities of all these systems are detailed in the paper. To date, the TRIMIS efforts have contributed significantly to more efficient information processing, thus ensuring continued quality health care through the DOD.     

Design and construction of a microdensitometer computer interface

This project consisted in modifying the output of a scanning microdensitometer so that a computer could accept and process the (optical) density versus position information gathered from radiographic film. The system functions were separated into two parts: the actual datagathering process, which required real-time response, and the calculation associated with the data. Separation of functions allowed a less expensive system overall while still preserving flexibility. For the real-time control computer, a relatively slow microprocessor-based system (Motorola MC6800) was chosen. The microdensitometer was modified to allow computer control of the scan. The density versus position information was digitized using optical shaft encoders. Cassette tape was used as a mass-storage medium for complete scans. Using an acoustic coupler, the microprocessor was cofigured to transmit accumulated data to a timeshare system for analysis. The results were retransmitted and displayed on a TV screen or printed on a line printer or teletype. The total cost of the microprocessor system was a little less than $5,000. The time required to produce the software was 50 to 100 hrs (approximately 1 week).     

The patient and the computer in the primary care consultation

Objective

Studies of the doctor–patient relationship have focused on the elaboration of power and/or authority using a range of techniques to study the encounter between doctor and patient. The widespread adoption of computers by doctors brings a third party into the consultation. While there has been some research into the way doctors view and manage this new relationship, the behavior of patients in response to the computer is rarely studied. In this paper, the authors use Goffman''s dramaturgy to explore patients'' approaches to the doctor''s computer in the consultation, and its influence on the patient–doctor relationship.

Design

Observational study of Australian general practice. 141 consultations from 20 general practitioners were videotaped and analyzed using a hermeneutic framework.

Results

Patients negotiated the relationship between themselves, the doctor, and the computer demonstrating two themes: dyadic (dealing primarily with the doctor) or triadic (dealing with both computer and doctor). Patients used three signaling behaviors in relation to the computer on the doctor''s desk (screen watching, screen ignoring, and screen excluding) to influence the behavior of the doctor. Patients were able to draw the doctor to the computer, and used the computer to challenge doctor''s statements.

Conclusion

This study demonstrates that in consultations where doctors use computers, the computer can legitimately be regarded as part of a triadic relationship. Routine use of computers in the consultation changes the doctor–patient relationship, and is altering the distribution of power and authority between doctor and patient.     

LAMP

A computer system for the management and analysis of clinical data is described. The system is implemented in the ANSI standard MUMPS language and runs on popular minicomputers. The system is designed to allow clinical invetigators or research assistants to define a data base, enter and edit data, produce patient-specific reports, and perform a variety of analyses on userspecified groups of subjects. Programmer intervention is not required at any stage of the management or analysis process, and on-line documentation provides a friendly environment for inexperienced users.     

GOG meets RPMIS

The Gynecologic Oncology Group (GOG) is a multiinstitutional, multidisciplinary cooperative group. Its clinical trials encompass the planning, initiation, execution, analysis, and presentation of results of management and treatment of patients with gynecologic cancer. The GOG Statistical Office, located at Roswell Park Memorial Institute, is responsible for data management and analysis of all patients entered into GOG protocols. Present annual accrual is approximately 1,600 patients; 37 protocols are active, while follow-up continues on 9 studies that are closed to patient entry. RPMIS¹ is a formatted video-based system of programs for file creation, data entry, editing, updating, retrieval, and report generation. It has been utilized in more than 500 intrainstitutional research studies at Roswell Park. In the past, data management for the GOG had been based on computer entry via punched cards, and on hand-filled reports. The switch to RPMIS use required major reorganization of the data-handling process and was first attempted on a limited basis. As the advantages of RPMIS became evident, the whole data management operation was gradually converted to the new system. In this paper, batch processing and RPMIS utilization are compared and contrasted in terms of time saved, human engineering, quality control, and satisfaction of information requests.     

MDA-Image: An environment of networked desktop computers for teleradiology/pathology

MDA-Image, a project of The University of Texas M. D. Anderson Cancer Center, is an environment of networked desktop computers for teleradiology/pathology. Radiographic film is digitized with a film scanner and histopathologic slides are digitized using a red, green, and blue (RGB) video camera connected to a microscope. Digitized images are stored on a data server connected to the institution's computer communication network (Ethernet) and can be displayed from authorized desktop computers connected to Ethernet. Images are digitized for cases presented at the Bone Tumor Management Conference, a multidisciplinary conference in which treatment options are discussed among clinicians, surgeons, radiologists, pathologists, radio-therapists, and medical oncologists. These radiographic and histologic images are shown on a large screen computer monitor during the conference. They are available for later review for follow-up or representation.     

The Health Maintenance Facility

The Health Maintenance Facility (HMF) is the code name for a space-based medical clinic. The HMF is an integral part of the U.S. sponsored space station program due to be launched in the late 1990s. Contained in this module will be equipment, facilities, and supplies that can be used to support space station crew health. The range of medical care will depend upon the skill of the crew, the tools available, and the support systems that can be used from earth. The design of this system and its heavy dependence upon computer resources provide an excellent model for looking forward into the earth based medical clinics of the future.     

A very large PC LAN as the basis for a hospital information system

Brigham and Women's Hospital is converting its financial, administrative and clinical information systems from a mini-computer environment to a platform based on MUMPS and a network of several thousand personal computers. This article describes the project rationale and status and provides an overview of the architecture of the new system. The initial results of the project indicate that the personal computer network can provide large amounts of processor power and storage at costs per unit of power and storage that are several times less expensive than the minicomputer environment. The performance of the converted Accounts Payable system indicates that the architecture can deliver acceptable performance.