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2.  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.
PMCID: PMC116196  PMID: 7719799
3.  User evaluation: PA catheter waveforms troubleshooting system. 
This paper reports on a user satisfaction survey of a system for consultation and education in troubleshooting pulmonary artery catheter waveforms. The twelve-item End-User Computing Satisfaction Questionnaire was used to assess users' ratings in four areas. On a scale of 1-5 (with 1 the lowest), the ratings were: Content, 3.5; Accuracy, 4.5; Format, 4.2; Ease of Use, 4.4, and Timeliness, 4.1. Comparison with ratings in a survey that included a variety of applications and settings is provided.
PMCID: PMC2247796  PMID: 7949850
4.  Providing clinicians with problem-based access to knowledge: troubleshooting pulmonary artery catheter waveforms. 
This paper describes a microcomputer system for providing computer-based access to expert knowledge in the area of troubleshooting pulmonary artery (PA) catheter waveforms. The system is used by both nurses and physicians in an 18-bed medical intensive care unit. Its dominant features are 1) problem-focused access to knowledge, and 2) heavy use of graphics and images to explicate knowledge. The system is used by both nurses and physicians in an 18-bed medical intensive care unit. An evaluation protocol is in place to examine the impact of the system on clinicians' knowledge, their decision-making skills, their satisfaction with the system, and costs of orientation related to PA waveform troubleshooting.
PMCID: PMC2248530  PMID: 8130493
5.  Adding Another Dimension to the COSTAR Diagnosis Directly for Multidisciplinary Care of the Elderly 
When care providers of many disciplines contribute to the care of patients, the ability to name the problems they define and manage becomes an important issue, both for accountability and communication. This paper describes the experience of one multidisciplinary group in adding a pre-existing vocabulary to the current COSTAR medical diagnosis directory. The vocabulary allowed nurses and social workers to name the physiological, psychosocial, environmental and health behavior problems they addressed in coordinating post-acute care for frail elderly patients. The vocabulary was used to describe 46% of the problems defined for this patient population. Eight terms needed to be added to make the vocabulary complete for describing problems managed by patient care coordinators.
PMCID: PMC2245516
6.  Translation of a Pharmacology Computer Aided Instruction Program from HyperCard to DIALOG Authoring Systems 
The Pharmacology Program, a computer aided instructional program has been designed for educating second year medical students about pharmacology. The Pharmacology Program is a PC based program which consists of an extensive pharmacology data base in both text and graphic formats. The program contains information on most of the drugs that are taught as part of the standard pharmacology course in medical school. This data base can be searched through the use of indexes, key-word searches, and hyper-media links between graphics and text. The program incorporates an intuitive, mouse-driven user interface. The program originated as a HyperCard Stack which ran only on Macintosh computers. We report the development of tools needed for the transport of a HyperCard application so that it is able to run in the DIALOG authoring system in the PC environment. In addition, we report on several aspects of user-interface design that are important in the design of multi-media software for medical education.
PMCID: PMC2245655
7.  HEMAVID: A Flexible Computer-Based Interactive Video Resource for Hematology 
This paper describes the design and development of HEMAVID, a computer-based interactive video (CBIV) resource for hematology. HEMAVID is a PC-based program that builds and maintains a versatile object-oriented database that indexes a collection of hematology slides residing on videodisc. Access to the database is flexible, allowing its use as: (1) an interactive visual reference, (2) a nucleus for the development and presentation of computer-aided instruction (CAI), and (3) image content in patient simulations. Each image in HEMAVID is associated with expert description, a prerequisite for the program's primary target population of medical students. Research fellows and physicians should also find it an effective resource for hematology review. To that end, the program incorporates an intuitive user interface; controlling the program requires only a “mouse” as a pointing device. HEMAVID's integration of expert knowledge and video imaging technology provides a unique alternative to traditional methods of teaching and reviewing hematological morphology.
PMCID: PMC2245322
8.  A COSTAR System for Hospital-Based Coordination of Long Term Care for the Elderly 
This paper describes an enhanced COSTAR (COmputer-STored Ambulatory Record) system to serve the needs of a hospital-based program for long-term care coordination and research. The COSTAR enhancements include a) new divisions of codes for Problems/Needs, Assessments/Outcomes and Interventions/Plans, b) a new summary document called the Long Term Care Plan, and c) an expanded vocabulary to meet the needs of nurses, social workers and nutritionists. The system is implemented in the Long Term Care Management Unit of the Massachusetts General Hospital (MGH) and at three MGH satellite health centers where the patients enrolled in this program receive their primary care.
PMCID: PMC2578040
9.  Using COSTAR to Assist Nurses in Hypertension Screening and Education 
COSTAR, a Computer-Stored Ambulatory Medical Record system, has been in use in the Family Practice/Primary Care Clinic, Pease Air Force Base, N.H., since November 1981. This paper describes a computer-based program to assist nurses in managing a hypertension screening and education program for known and suspected hypertensives. The program includes: 1) data record for five day blood pressure screening and patient education data; 2) a patient-specific instruction sheet containing information about the patient's medications and diet; 3) a drug interaction check list advising the nurse of potential interactions of drugs active for that patient. Patients' evaluations of the computer-generated instruction sheet are included.
PMCID: PMC2578202
11.  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.
PMCID: PMC2232624  PMID: 10566405
12.  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.
PMCID: PMC2232518  PMID: 10566489
13.  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.
PMCID: PMC2232378  PMID: 9929193
14.  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.
PMCID: PMC2232236  PMID: 9929315
15.  Using web technology and Java mobile software agents to manage outside referrals. 
A prototype, web-based referral application was created with the objective of providing outside primary care providers (PCP's) the means to refer patients to the Massachusetts General Hospital and the Brigham and Women's Hospital. The application was designed to achieve the two primary objectives of providing the consultant with enough data to make decisions even at the initial visit, and providing the PCP with a prompt response from the consultant. The system uses a web browser/server to initiate the referral and Java mobile software agents to support the workflow of the referral. This combination provides a light client implementation that can run on a wide variety of hardware and software platforms found in the office of the PCP. The implementation can guarantee a high degree of security for the computer of the PCP. Agents can be adapted to support the wide variety of data types that may be used in referral transactions, including reports with complex presentation needs and scanned (faxed) images Agents can be delivered to the PCP as running applications that can perform ongoing queries and alerts at the office of the PCP. Finally, the agent architecture is designed to scale in a natural and seamless manner for unforeseen future needs.
PMCID: PMC2232210  PMID: 9929190
16.  DXplain on the Internet. 
DXplain, a computer-based medical education, reference and decision support system has been used by thousands of physicians and medical students on stand-alone systems and over communications networks. For the past two years, we have made DXplain available over the Internet in order to provide DXplain's knowledge and analytical capabilities as a resource to other applications within Massachusetts General Hospital (MGH) and at outside institutions. We describe and provide the user experience with two different protocols through which users can access DXplain through the World Wide Web (WWW). The first allows the user to have direct interaction with all the functionality of DXplain where the MGH server controls the interaction and the mode of presentation. In the second mode, the MGH server provides the DXplain functionality as a series of services, which can be called independently by the user application program.
PMCID: PMC2232149  PMID: 9929291
17.  Long-term changes in compliance with clinical guidelines through computer-based reminders. 
We evaluate the effectiveness of computer-based reminders in improving compliance with preventive medicine screening guidelines and examine the long-term impact of these reminders. Physicians in an ambulatory care practice were given a summary health maintenance report of preventive screening items at each scheduled patient visit. The electronic medical record (COSTAR) in use in this practice was programmed to integrate 13 clinical guidelines into the routine flow of care. Mean performance of 10 out of 13 health maintenance measures improved in the year following introduction of the integrated guideline report (p less than .001 by chi-square test for 8 items, p less than .01 for 2 items). Five years after the report was introduced, improvement in mean performance persisted for 7 measures (p less than .001 by chi-square test), compliance improved for one additional measure (p less than .001), and improvement disappeared for three measures that had shown improvement in the first year of the intervention.
PMCID: PMC2232093  PMID: 9929268
18.  Puya: a method of attracting attention to relevant physical findings. 
Puya is a method that compares the physical exam in an electronic clinical note with a set of stereotypical physical exam sentences that have been previously classified as "normal". The note is then displayed in a web browser with normal findings clearly delineated. The list of stereotypical sentences comes from a set of physical findings found within extensive electronic medical record. This list is then screened to select only those that represent "normal" findings, a process that yields 96% total agreement among 4 clinicians surveyed. This final list of stereotypical "normal" sentences accounts for 64% of the clinical narrative text. Sentences in the clinical note that do not match sentences in the "normal" list are assumed to be "abnormal". Puya screened 98 clinical notes consisting of 610 individual sentences. Puya achieved a sensitivity of 100%, a specificity of 63%, a positive predictive value of 44% and a negative predictive value of 100%. This leads to an application that reduces informational noise.
PMCID: PMC2233598  PMID: 9357678
19.  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.
PMCID: PMC2233558  PMID: 9357696
20.  Evaluation of a decision support system for pressure ulcer prevention and management: preliminary findings. 
A decision support system for prevention and management of pressure ulcers was developed based on AHCPR guidelines and other sources. The system was implemented for 21 weeks on a 20-bed clinical care unit. Fifteen nurses on that unit volunteered as subjects of the intervention to see whether use of the system would have a positive effect on their knowledge about pressure ulcers and on their decision-making skills related to this topic. A similar care unit was used as a control. In addition, the system was evaluated by experts for its instructional adequacy, and by end users for their satisfaction with the system. Preliminary results show no effect on knowledge about pressure ulcers and no effect on clinical decision making skills. The system was rated positively for instructional adequacy, and positively for user satisfaction. User interviews related to satisfaction supplemented the quantitative findings. A discussion of the issues of conducting experiments like this in today's clinical environment is included.
PMCID: PMC2233550  PMID: 9357626
21.  Using software agents to maintain autonomous patient registries for clinical research. 
A software agent is an application that can function in an autonomous and intelligent fashion. We have used mobile software agents to maintain clinicians' patient research databases (patient registries). Agents were used to acquire data from the clinician and place it into the registries, copy data from hospital databases into the registries, and report data from the registries. The agents were programmed with the intelligence to navigate through complex network security, interact with legacy systems, and protect themselves from various forms of failure at multiple levels. To maximize the separation between our system and the hospital information infrastructure we often used Java, a platform-independent language, to program and distribute our software agents. By using mobile agents, we were able to distribute the computing time required by these applications to underutilized host machines upon which the registries could be maintained.
PMCID: PMC2233465  PMID: 9357591
22.  MedWeaver: integrating decision support, literature searching, and Web exploration using the UMLS Metathesaurus. 
Integrating functions from disparate and widely-distributed information systems has been an interest of the medical informatics community for some time. Barriers to progress have included the lack of network-accessible information sources, inadequate methods for inter-system messaging, and lack of vocabulary translation services. With the advent of the World Wide Web (WWW) and the evolution of the National Library of Medicine's Unified Medical Language System (UMLS), it is now possible to develop applications that integrate functions from diverse, distributed systems. In this paper we describe one such system, MedWeaver, a WWW application that integrates functions from a decision support application (DXplain), a literature searching system (WebMedline), and a clinical Web searching system (CliniWeb) using the UMLS Metathesaurus for vocabulary translation. This system demonstrates how application developers can design systems around anticipated clinical information needs and then draw together the needed content and functionality from diverse sources.
PMCID: PMC2233429  PMID: 9357674
23.  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.
PMCID: PMC2233241  PMID: 9357726
24.  Using HL7 and the World Wide Web for unifying patient data from remote databases. 
W3-EMRS is an architecture designed to access clinical data from remote heterogeneous electronic medical record system (EMRS) databases. We describe the technologies used in an experimental implementation of W3-EMRS that concurrently collects data from several sources and presents them in an integrated set of views. After describing some of the organizational constraints, the architectural decision, implementation methodology, and operation of the completed project are discussed.
PMCID: PMC2233237  PMID: 8947745
25.  Collaborative medical informatics research using the Internet and the World Wide Web. 
The InterMed Collaboratory is an interdisciplinary project involving six participating medical institutions. There are two broad mandates for the effort. The first is to further the development, sharing, and demonstration of numerous software and system components, data sets, procedures and tools that will facilitate the collaborations and support the application goals of these projects. The second is to provide a distributed suite of clinical applications, guidelines, and knowledge-bases for clinical, educational, and administrative purposes. To define the interactions among the components, datasets, procedures, and tools that we are producing and sharing, we have identified a model composed of seven tiers, each of which supports the levels above it. In this paper we briefly describe those tiers and the nature of the collaborative process with which we have experimented.
PMCID: PMC2233227  PMID: 8947641

Results 1-25 (46)