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Cybermedicine

Warner V. Slack, M.D. Warner V. Slack, M.D. Center for Clinical Computing, Center for Clinical Computing, Harvard Medical School, and Harvard Medical School, and Beth Israel Deaconess Medical Center Beth Israel Deaconess Medical Center

Seven Principles of Clinical Computing


F Information should be captured F Information should be captured

directly at computer terminals directly at computer terminals located at the point of each located at the point of each transaction, not on pieces of paper. transaction, not on pieces of paper.

Seven Principles of Clinical Computing


F Information captured at a terminal F Information captured at a terminal

or automated device anywhere in or automated device anywhere in the hospital or clinic should be the hospital or clinic should be available immediately, if needed, at available immediately, if needed, at any other terminal. any other terminal.

Seven Principles of Clinical Computing


F The response time of the computer F The response time of the computer

should be rapid. should be rapid.

Seven Principles of Clinical Computing


F The computer should be reliable F The computer should be reliable

and accurate. and accurate.

Seven Principles of Clinical Computing


F The computer programs should be F The computer programs should be

friendly to the user and reinforce friendly to the user and reinforce the users behavior. the users behavior.

Seven Principles of Clinical Computing


F There should be a common registry F There should be a common registry

for all patients. for all patients.

Seven Principles of Clinical Computing


F Confidentiality should be protected. F Confidentiality should be protected.

Clinical Computing
Registration Registration F Laboratories F Laboratories F Clinical Departments F Clinical Departments F Finance F Finance F Clinical use F Clinical use
F F

Clinical Use
Provides clinical information upon request Provides clinical information upon request F Gives support with decisions F Gives support with decisions F Assists with communication F Assists with communication F Assists with clinical practice F Assists with clinical practice F Assists with education F Assists with education
F F

Clinical Use
F Provides clinical information upon request F Provides clinical information upon request

Patient ID: Poxtun, Monnotte Patient ID: Poxtun, Monnotte 9999999 Paxton,Minnette 04/21/03 F 97 111-11-1111 9999999 Paxton,Minnette 04/21/03 F 97 111-11-1111 (Access Restricted) (Access Restricted) Arthur Marguetite Richard M Townsend Arthur Marguetite Richard M Townsend OK? Y // OK? Y //

00000000 Doe, John 00000000 Doe, John

3/21/70 31M 3/21/70 31M

1. All Labs 11. Result Over Time 1. All Labs 11. Result Over Time 2. Blood Bank 12. Microbiology 2. Blood Bank 12. Microbiology 3. Blood Gas 13. Neurophysiology 3. Blood Gas 13. Neurophysiology 4. Cardiology 14. Online Medical Record 4. Cardiology 14. Online Medical Record 5. Chemistry 15. Outside/Lexington Lab 5. Chemistry 15. Outside/Lexington Lab 6. Cytogenics 16. Pharmacy 6. Cytogenics 16. Pharmacy 7. Cytology 17. Pulmonary Function 7. Cytology 17. Pulmonary Function 8. Demographics 18. Radiology 8. Demographics 18. Radiology 9. Electrocardiograms 19. Clinical Pathology 9. Electrocardiograms 19. Clinical Pathology 10. Hematology 20. Urinalysis 10. Hematology 20. Urinalysis

00000000 Med *** Current Medications

Admitted: 03/13

Room: 12R-1275

Dose Route Schedule Start (-End) Medication ----------------------------------- IVs and injectibles ------------------------------------------2 GM IV PIGGY QBH 08/16

Cefazolin

--------------------------------------- PO and Non-injectibles ---------------------------------------------Acyclovir 200 MG PO CAP SX/D 08/13 Clotrimazole 10 MG PO TAB TC QID 08/13 Potassium Chloride 40 MEQ PO TAB QD 08/19

----------------------------------- PRN, Let-call, and Single dose---------------------------------------650 MG 10 ML 100 ML 6000 UNITS 10 MG PO TAB PR SUPP IRR IRR PO SUSP PO TAB FS Q4H24HR FS PRN LC LC PRN QID PRN Q6H 08/13 08/18 08/13 08/13 08/13

Acetaminophen Bisacodyl Glotzers Solution Nystatin Prochorperazine

Clinical Use
F Gives support with decisions F Gives support with decisions

Clinical Use
F Gives support with decisions F Gives support with decisions
Advice and consultation Advice and consultation

Clinical Use
F Gives support with decisions F Gives support with decisions
Advice and consultation Advice and consultation

Acid-Base Evaluation Acid-Base Evaluation

ELECTROLYTE AND ACID-BASE EVALUATION:: ELECTROLYTE AND ACID-BASE EVALUATION

Saturday March 17, 2001 2:37 pm Saturday March 17, 2001 2:37 pm To enter your own values, enter _ (underscore) To enter your own values, enter _ (underscore) Patient ID: Patient ID:

Clinical Use
F Gives support with decisions F Gives support with decisions
Advice and consultation Advice and consultation

Acid-Base Evaluation Acid-Base Evaluation Drug Information Drug Information

Drug Information Drug Information


F Hospital Formulary Information F Hospital Formulary Information F Infectious Disease - Therapy and F Infectious Disease - Therapy and

Guidelines Guidelines F Medications - Descriptions, Interactions, F Medications - Descriptions, Interactions, Costs Costs F Physician Desk Reference - PDR F Physician Desk Reference - PDR

For Prozac For Prozac


1. Description 7. Drug Interactions 1. Description 7. Drug Interactions 2. Clinical Pharmacology 8. Adverse Reactions 2. Clinical Pharmacology 8. Adverse Reactions 3. Indications and Usage 9. Drug Abuse 3. Indications and Usage 9. Drug Abuse 4. Contraindications 10. Overdosage 4. Contraindications 10. Overdosage 5. Warnings 11. Dosage 5. Warnings 11. Dosage 6. Precautions 12. How Supplied 6. Precautions 12. How Supplied

Clinical Use
F Gives support with decisions F Gives support with decisions
Advice and consultation Advice and consultation

Acid-Base Evaluation Acid-Base Evaluation Drug Information Drug Information Clinical Formulas Clinical Formulas

Clinical Formulas Clinical Formulas


1. Alveolar-Arterial Oxygen Difference 1. Alveolar-Arterial Oxygen Difference 2. Free Water Deficit or Sodium Deficit 2. Free Water Deficit or Sodium Deficit 3. Calcium Correction for Hypoalbuminemia 3. Calcium Correction for Hypoalbuminemia 4. Creatinine Clearance 4. Creatinine Clearance 5. Fractional Excretion of Sodium 5. Fractional Excretion of Sodium 6. QT Interval Correction 6. QT Interval Correction 7. Body surface Area and Body Mass Index 7. Body surface Area and Body Mass Index 8. Hemodynamics 8. Hemodynamics 9. Bayes Theorem 9. Bayes Theorem

Free Water Deficit or Sodium Deficit Free Water Deficit or Sodium Deficit Free H20 Deficit = TBW -TBW x (Desired Na/Measured Na) NA Deficit = TBW x (Desired NA - Measured Na) TBW = WGT X [0.6 (Male) or 0.5 (Female)] Weight = lbs or Male or Female? Current Serum Na = Desired Na = Free H20 Deficit = 3.6 kg 57 Female mEq/L 160 mEq/L 140 Liters

Notes: 1) Correct about half of total deficit in first 24 hours 2) Correction rate should be 0.5 mEq/L/hr (12 mEq/day) 3) Recompile deficit frequently 4) Add insensible fluid losses to computed values Look at References? N

Clinical Use
F Gives support with decisions F Gives support with decisions
Advice and consultation Advice and consultation

Acid-Base Evaluation Acid-Base Evaluation Drug Information Drug Information Clinical Formulas Clinical Formulas HIV ProtoCall HIV ProtoCall

Welcome to ***HIV ProtoCall*** Welcome to ***HIV ProtoCall***


An information guide to research drugs An information guide to research drugs for human immunodeficienvy virus for human immunodeficienvy virus infection and associated opportunistic infection and associated opportunistic infections. infections. Press <Enter> Press <Enter>

Clinical Use
F Gives support with decisions F Gives support with decisions
Advice and consultation Advice and consultation

Acid-Base Evaluation Acid-Base Evaluation Drug Information Drug Information Clinical Formulas Clinical Formulas HIV ProtoCall HIV ProtoCall Withdrawal of therapy Withdrawal of therapy

.. Withdrawal of Therapy Withdrawal of Therapy Life-Sustaining Treatment Guidelines Life-Sustaining Treatment Guidelines 1. Overview 1. Overview 2. Definitions 2. Definitions 3. Treatment Options 3. Treatment Options 4. Documentation 4. Documentation

Please choose and option: Please choose and option:

.. .. Withdrawal of Therapy Withdrawal of Therapy Overview Overview 1. Policy Statement 1. Policy Statement 2. DNR vs. CPR not Indicated 2. DNR vs. CPR not Indicated 3. Withholding/Withdrawing Other Treatment 3. Withholding/Withdrawing Other Treatment 4. Support and Counseling 4. Support and Counseling Choose option(s), or A for All: Choose option(s), or A for All:

Clinical Use
F Gives support with decisions F Gives support with decisions
Advice and consultation Advice and consultation Bibliographic retrieval (PaperChase) Bibliographic retrieval (PaperChase)

..

..
PaperChase PaperChase

((MEDLINE now has over nine million references to articles from over MEDLINE now has over nine million references to articles from over forty-three hundred journals) forty-three hundred journals) LOOK FOR: LOOK FOR:

For HELP, type ? and press <ENTER> For HELP, type ? and press <ENTER>

Clinical Use
F Gives support with decisions F Gives support with decisions
Advice and consultation Advice and consultation Bibliographic retrieval (PaperChase) Bibliographic retrieval (PaperChase)
Searching the clinical database Searching the clinical database

..

C ll ii n Q u e rr y C nQue y

Sat Mar 17, 2001 3:07 pm Sat Mar 17, 2001 3:07 pm

ClinQuery covers 495,448 admissions from 1984 through ClinQuery covers 495,448 admissions from 1984 through 01/31/01. 01/31/01.

Please enter the year or range of years (e.g. 85-90) you are Please enter the year or range of years (e.g. 85-90) you are going to search. going to search. Year(s): 1999 Year(s): 1999

..

C ll ii n Q u e rr y C nQue y

Year 99 Year 99

Sat Mar 17, 2001 3:09 pm Sat Mar 17, 2001 3:09 pm

Look For: age Look For: age 1. Admin/Demography 1. Admin/Demography 2. Laboratory Results 2. Laboratory Results 3. Blood Bank 3. Blood Bank 4. Medications 4. Medications 5. Surgical Pathology 5. Surgical Pathology 6. Radiology 6. Radiology 7. Cardiac Cath 7. Cardiac Cath 8. Outpatient 8. Outpatient 9. Diagnosis/procedure 9. Diagnosis/procedure 10. DRG 10. DRG

Or enter ? for more information Or enter ? for more information

C ll ii n Q u e rr y C nQue y Age Age Choice Values Choice Values 1) <--- .9 1) <--- .9 2) 1.0-9.9 2) 1.0-9.9 3) 10.0-17.9 3) 10.0-17.9 4) 18.0-19.9 4) 18.0-19.9 5) 20.0-29.9 5) 20.0-29.9 6) 30.0-39.9 6) 30.0-39.9 7) 40.0-49.9 7) 40.0-49.9 8) 50.0-59.9 8) 50.0-59.9 9) 60.0-64.9 9) 60.0-64.9 A) 65.0-69.9 A) 65.0-69.9 B) 70.0-79.9 B) 70.0-79.9 C) 80.0 ---> C) 80.0 ---> Choices: Choices:

Year 1999 Year 1999

Sat Mar 17, 2001 3:09 pm Sat Mar 17, 2001 3:09 pm

Admissions Admissions 5145 5145 1 1 91 91 261 261 2723 2723 5614 5614 3427 3427 3602 3602 1847 1847 2009 2009 4278 4278 3961 3961

Clinical Use
F Gives support with decisions F Gives support with decisions
Advice and consultation Advice and consultation Bibliographic retrieval (PaperChase) Bibliographic retrieval (PaperChase)
Searching the clinical database Searching the clinical database

Alerts and reminders Alerts and reminders

Clinical Use
F Assists with communication F Assists with communication

E-Mail Inquire If Message Read Read Mail Write Message Retract Mail Inquire If Message Read Personal Menu Help

E-Mail Retract Mail Read Mail Write Message Retract Mail Inquire If Message Read Personal Menu Help

Clinical Use
F Assists with clinical practice F Assists with clinical practice

Clinicians Option: Clinicians Option:


1. Admissions or Labs by Service, Firm or Team 1. Admissions or Labs by Service, Firm or Team 2. Adverse Drug Reaction Reporting 2. Adverse Drug Reaction Reporting 3. Confidential Counseling for House Staff 3. Confidential Counseling for House Staff 4. Cross Coverage Options 4. Cross Coverage Options 5. Incomplete Medical Records 5. Incomplete Medical Records 6. Personal Patient Lookup 6. Personal Patient Lookup 7. Resident/Medical Student Log 7. Resident/Medical Student Log 8. View Clinicians Hospitalized Patients 8. View Clinicians Hospitalized Patients

Clinicians Options
F Confidential counseling for house F Confidential counseling for house

staff staff

.. ..
House Staff Support and Consultation House Staff Support and Consultation From time to time a House Officer or Fellow may have a personal From time to time a House Officer or Fellow may have a personal matter that motivates him or her to seek professional counseling. matter that motivates him or her to seek professional counseling. Psychiatric consultation and referral that is confidential and Psychiatric consultation and referral that is confidential and independent of administrative reporting is readily available. independent of administrative reporting is readily available.

Please feel free to call or page any of the psychiatrists listed on the Please feel free to call or page any of the psychiatrists listed on the next screen. next screen. Your call will remain confidential. Your call will remain confidential.

Confidential Counseling for House Staff Confidential Counseling for House Staff
Academic Year Academic Year 1995 1995 1996 1996 1997 1997 1998 1998 1999 1999 2000 2000 Accesses Accesses 388 388 380 380 382 382 424 424 330 330 287 287

Clinical Use
F Assists with education F Assists with education

Clinical Use
F Assists with education F Assists with education

-ECG case of the week -ECG case of the week

..

*** Select ECG case of the week *** Select ECG case of the week
1. 12/30/96 1. 12/30/96 First line of description First line of description 83 yr old woman with CHF. What is the likely etiology? Clue :: 83 yr old woman with CHF. What is the likely etiology? Clue axis axis 2. 12/30/96 2. 12/30/96 First line of description First line of description 86 yr old man with slow pulse. 86 yr old man with slow pulse. 3. 12/30/96 3. 12/30/96 First line of description First line of description 29 yr old man with chest pain/dyspnea. Diagnosis still possible 29 yr old man with chest pain/dyspnea. Diagnosis still possible despite artifact. despite artifact.

Description : Description : The patient is an elderly woman with a The patient is an elderly woman with a known history of left bundle branch block known history of left bundle branch block who presented to the emergency ward with who presented to the emergency ward with shortness of breath. shortness of breath. Do you wish to view the wave format (approx Do you wish to view the wave format (approx 30 seconds)? (Y/N) Y// 30 seconds)? (Y/N) Y//

ANSWER TO THIS QUIZ DX: Sinus bradycardia, LBBB with primary st-t wave changes The ECG demonstrates a left bundle branch block morphology with primary biphasic and inverted t waves in leads 2,3, and F. Uncomplicated bundle branch blocks should have seconday t wave changes. That is the stt waves should be opposite in direction to the major vector of the QRS. For example, if this ECG with LBBB was uncomplicated the stt waves in the inferior leads would be upright. This patient has inverted t waves suggesting that a primary or ischenic process is evolving in the inferior distribution. She did in fact rule in for a myocardial infarction with a CK of 700 and 21% MB fraction. This message is that ischemic ECG changes can be read in the presence of a bundle branch block.

Clinical Use
F Assists with education F Assists with education

-ECG case of the week -ECG case of the week -Universal precautions -Universal precautions

.. ..

Standard/Universal Precautions Standard/Universal Precautions


Welcome to your training in Welcome to your training in standard/universal precautions standard/universal precautions

To quit <tab> To quit <tab>

To continue <enter> To continue <enter>

Successful Completion

First time First time At a later date At a later date

881 (89%) 881 (89%) 70 (7%) 70 (7%)

Preference - Computer vs. Infection Control Personnel


No Preferences Infection Control Computer

7% 2% 91%

91%

Reaction to Computer Interview Reaction to Computer Interview


100 Percentage of Physicians 80 60

89
40 20 0 Worthwhile

60

78

Interesting

Time About Right

Nursing Option Nursing Option


1. Condition Display 1. Condition Display 2. Dietary Orders 2. Dietary Orders 3. Functional Health Pattern Assessment 3. Functional Health Pattern Assessment 4. Last Primary Nurse 4. Last Primary Nurse 5. Patient Classification System 5. Patient Classification System 6. Pre-operative Telephonic Enter/Edit 6. Pre-operative Telephonic Enter/Edit

F Evaluating Cybermedicine F

F Use of the system by voluntary users F Use of the system by voluntary users

Beth Israel Deaconess Use of Patient Lookup: Beth Israel Deaconess Use of Patient Lookup: Inpatients and Outpatients Inpatients and Outpatients 80,000
Number of Lookups Number of Lookups During a Typical Week During a Typical Week

80,000 70,000 70,000 60,000 60,000 50,000 50,000 40,000 40,000 30,000 30,000 20,000 20,000 10,000 10,000 0 0

44,383 44,383 21,497 21,497 13,229 13,229 34,614 34,614 35,229 35,229 27,023 27,023

4,080 4,080 12,688 12,688

27,707 27,707

30,264 30,264

1984 1984

1988 1988

1992 1992

1994 1994

1998 1998

Inpatient Lookups Inpatient Lookups

Outpatient Lookups Outpatient Lookups

Use of Patient Lookup According to Type of Inquiry Use of Patient Lookup According to Type of Inquiry at Beth Israel Deaconess, at Beth Israel Deaconess, April 27-May 3, 1998 April 27-May 3, 1998
All Labs Most Recent Results All Labs Most Recent Results Demographics Demographics Chemistry Chemistry Radiology Radiology Narrative Notes Narrative Notes Cardiology Cardiology Pathology Pathology M icrobiology M icrobiology Hematology Hematology Blood Bank Blood Bank Pharmacy Pharmacy Neurophysiology Neurophysiology Pulmonary Function Pulmonary Function Total Total Inpatients Inpatients 17,018 17,018 3,277 3,277 4,310 4,310 2,681 2,681 1,163 1,163 1,548 1,548 528 528 1,990 1,990 1,014 1,014 743 743 753 753 96 96 108 108 35,229 35,229 Outpatients Outpatients 10,044 10,044 9,420 9,420 4,793 4,793 6,028 6,028 3,893 3,893 2,697 2,697 3,562 3,562 1,001 1,001 1,786 1,786 439 439 282 282 251 251 187 187 44,383 44,383 Total Total 27,062 27,062 12,697 12,697 9,103 9,103 8,709 8,709 5,056 5,056 4,245 4,245 4,090 4,090 2,991 2,991 2,800 2,800 1,182 1,182 1,035 1,035 347 347 295 295 79,612 79,612

Passwords to the CCC Passwords to the CCC Cybermedicine System at Cybermedicine System at Beth Israel Deaconess Beth Israel Deaconess (winter 2000/2001) (winter 2000/2001) Staff Physicians 1,034 Staff Physicians 1,034 Nurses 1,983 Nurses 1,983 Clinical Fellows 258 Clinical Fellows 258 House Officers 630 House Officers 630 Medical Students 395 Medical Students 395

Use of Patient Lookup Use of Patient Lookup


Others Others Nurses Nurses Staff Doctors Staff Doctors Fellows Fellows Students Students Residents Residents 0 0 10 10 20 20 30 30 40 40 50 50

Lookups Per User Per Week Lookups Per User Per Week

Electronic Mailbox Electronic Mailbox


Students Students Residents Residents Fellows Fellows Staff Staff Nurses Nurses Others Others Total Total 2,134 2,134 9,385 9,385 1,396 1,396 2,455 2,455 10,980 10,980 3,650 3,650 30,000 30,000

F Use of the system by voluntary users F Use of the system by voluntary users F Attitude toward the system F Attitude toward the system

Effect on Work Effect on Work


Accuracy
Definitely worse Probably worse No difference Probably better Definitely better Total

Speed
15 24 54 192 260 545

Ease
8 13 48 182 294 545

Interest
3 10 147 190 195 545

4 13 88 204 236 545

E-mail Questionnaire Results E-mail Questionnaire Results


F 89% felt e-mail made life easier F 89% felt e-mail made life easier F 11% felt e-mail made life harder F 11% felt e-mail made life harder F 61% felt e-mail had a humanizing F 61% felt e-mail had a humanizing

influence influence F 13% felt e-mail had a dehumanizing F 13% felt e-mail had a dehumanizing influence influence

F Use of the system by voluntary users F Use of the system by voluntary users F Attitude toward the system F Attitude toward the system F Effect of the system on the quality of F Effect of the system on the quality of

medical care medical care

F Indirect Evidence F Indirect Evidence

If it can be agreed that doctors for If it can be agreed that doctors for the most part engage in their the most part engage in their diagnostic efforts with good reason diagnostic efforts with good reason and good will and with beneficial and good will and with beneficial results for their patients results for their patients

F Indirect Evidence F Indirect Evidence

then the computing system that offers then the computing system that offers them the information they have them the information they have requested ,, with more ease, speed requested with more ease, speed reliability, and accuracy than is otherwise reliability, and accuracy than is otherwise possible, is improving the quality of care. possible, is improving the quality of care.

F Direct Evidence F Direct Evidence

The time to act on important clinical The time to act on important clinical events, such as the need for a events, such as the need for a vaccination or change in a medication vaccination or change in a medication causing adverse side effects is causing adverse side effects is significantly reduced when the physician significantly reduced when the physician is reminded or alerted by the computer of is reminded or alerted by the computer of the need to act. the need to act.

Clinician Response Time

Reminders Alerts
Intervention
0 50 100 150 200 250 300 350 400

Control
450 500

(days)

F Direct Evidence F Direct Evidence

Bates, Kuperman, Teich, et al: Bates, Kuperman, Teich, et al: Physicians at BWH now routinely Physicians at BWH now routinely use the computing system to order use the computing system to order laboratory tests and prescribe laboratory tests and prescribe medications medications

F Direct Evidence F Direct Evidence

Bates, Kuperman, Teich, et al: Bates, Kuperman, Teich, et al: Errors have been dramatically reduced at Errors have been dramatically reduced at BWH with their order entry and alerting BWH with their order entry and alerting system; e.g., serious errors in system; e.g., serious errors in medications have been reduced by 55 medications have been reduced by 55 percent. percent.

F ERRORS IN MEDICINE F ERRORS IN MEDICINE

To Err is Human To Err is Human (Institute of Medicine Report, fall 1999) (Institute of Medicine Report, fall 1999) as many as 98,000 people die in any as many as 98,000 people die in any given year from medical errors that occur given year from medical errors that occur in hospitals. in hospitals.

F Errors in Medicine F Errors in Medicine

The extent of the problem is debatable The extent of the problem is debatable but but Most would agree there is a problem Most would agree there is a problem

F Errors in Medicine F Errors in Medicine

Two approaches to mistakes by doctors: Two approaches to mistakes by doctors: To expose and criticize To expose and criticize or, far better, or, far better, To make it as easy as possible for the To make it as easy as possible for the doctor to practice good medicine doctor to practice good medicine

F Errors in Medicine F Errors in Medicine

My argument: We know enough My argument: We know enough already to reduce substantially already to reduce substantially important errors in medicine through important errors in medicine through the good use of cybermedicine. the good use of cybermedicine.

F Errors in Medicine F Errors in Medicine

If the cybermedicine programs provide the If the cybermedicine programs provide the results of diagnostic studies immediately results of diagnostic studies immediately upon request, with abnormal and critical upon request, with abnormal and critical values highlighted to avoid their being values highlighted to avoid their being overlooked; overlooked;

F Errors in Medicine F Errors in Medicine

If the cybermedicine programs offer If the cybermedicine programs offer unsolicited alerts and reminders unsolicited alerts and reminders about clinical events that need about clinical events that need attention, either immediately or in the attention, either immediately or in the near future; near future;

F Errors in Medicine F Errors in Medicine

If the cybermedicine programs offer If the cybermedicine programs offer advice and consultation, when advice and consultation, when requested, about diagnosis and requested, about diagnosis and treatment; treatment;

F Errors in Medicine F Errors in Medicine

If the cybermedicine programs offer If the cybermedicine programs offer ready access to current, reliable ready access to current, reliable medical literature; medical literature;

F Errors in Medicine F Errors in Medicine

If the cybermedicine programs offer access If the cybermedicine programs offer access to information about the diagnosis and to information about the diagnosis and treatment of patients from the past (with treatment of patients from the past (with protection of confidentiality) for protection of confidentiality) for comparison with the diagnosis and comparison with the diagnosis and treatment of patients in the present; treatment of patients in the present;

F Errors in Medicine F Errors in Medicine

If the cybermedicine programs assist If the cybermedicine programs assist with (or better, eliminate) with (or better, eliminate) administrative chores, thereby administrative chores, thereby freeing more time for medical freeing more time for medical matters, matters,

F Errors in Medicine F Errors in Medicine

And if the cybermedicine programs And if the cybermedicine programs have educational value, have educational value,

F Errors in Medicine F Errors in Medicine

Then the doctor is far less likely to Then the doctor is far less likely to make mistakes in the practice of make mistakes in the practice of medicine. medicine.

F Use of the system by voluntary users F Use of the system by voluntary users F Attitude toward the system F Attitude toward the system F Effect of the system on the quality of F Effect of the system on the quality of

medical care medical care


F The Teaching Power of Cybermedicine F The Teaching Power of Cybermedicine

F Teaching F Teaching

In the tradition of John Dewey, who In the tradition of John Dewey, who advocated learning by doing, advocated learning by doing, cybermedicine promotes learning in cybermedicine promotes learning in the context of caring for real patients. the context of caring for real patients.

F Teaching F Teaching

e.g., if a medical student caring for an e.g., if a medical student caring for an elderly man is informed by the computer elderly man is informed by the computer that the patient has a low serum Na, a that the patient has a low serum Na, a low BUN, and a chest film that shows low BUN, and a chest film that shows hilar adenopathy with pleural effusion... hilar adenopathy with pleural effusion...

F Teaching F Teaching

the student can request computerthe student can request computerbased consultation on diagnosis and based consultation on diagnosis and treatment (data from the labs are treatment (data from the labs are transferred to the consultation transferred to the consultation programs automatically) programs automatically)

F Teaching F Teaching

and discover (or be reminded) that and discover (or be reminded) that the findings are suggestive of oat cell the findings are suggestive of oat cell carcinoma of the lung with carcinoma of the lung with inappropriate secretion of antidiuretic inappropriate secretion of antidiuretic hormone hormone

F Teaching F Teaching

and then use ClinQuery to find and then use ClinQuery to find information on other patients with information on other patients with these abnormalities these abnormalities

F Teaching F Teaching

use PaperChase to search for use PaperChase to search for related articles in the medical related articles in the medical literature literature

F Teaching F Teaching

and use electronic mail to communicate and use electronic mail to communicate with other students, house officers, or with other students, house officers, or staff physicians, all from the same staff physicians, all from the same computer terminal. computer terminal.

F Use of the system by voluntary users F Use of the system by voluntary users F Attitude toward the system F Attitude toward the system F Effect of the system on the quality of F Effect of the system on the quality of

medical care medical care


F The Teaching Power of Cybermedicine F The Teaching Power of Cybermedicine

F Effect of the System on Hospital Finances F Effect of the System on Hospital Finances

Time needed to collect bills in relation to use of Time needed to collect bills in relation to use of computing programs at Beth Israel Hospital computing programs at Beth Israel Hospital
80 TIME TO COLLECT BILLS (DAYS) 70 60 50 40 30 20 10 0 1976 1977 1978 1979 1980 1981 1982 FISCAL YEAR Clinical Programs Registration Programs

Time needed to collect bills in relation to use of Time needed to collect bills in relation to use of computing programs at Brigham & Womens computing programs at Brigham & Womens Hospital Hospital
100 TIME TO COLLECT BILLS (DAYS) 90 80 70 60 50 40 30 20 10 0 1982 1983 1984 1985 1986 1987 1988 FISCAL YEAR Registration Programs Financial Programs Clinical Programs

F Use of the system by voluntary users F Use of the system by voluntary users F Attitude toward the system F Attitude toward the system F Effect of the system on the quality of F Effect of the system on the quality of

medical care medical care


F The Teaching Power of Cybermedicine F The Teaching Power of Cybermedicine

F Effect of the System on Hospital Finances F Effect of the System on Hospital Finances F Cost of the System F Cost of the System

Confidentiality

Measures in Use for Protection Measures in Use for Protection of Patient Confidentiality of Patient Confidentiality
F All users are told that the password F All users are told that the password

is equivalent to a legal signature, is equivalent to a legal signature, and that under no circumstances and that under no circumstances should it be shared with anyone. should it be shared with anyone.

Measures in Use for Protection of Measures in Use for Protection of Patient Confidentiality Patient Confidentiality

F Access can be restricted by F Access can be restricted by

password and by terminal location. password and by terminal location.

Measures in Use for Protection Measures in Use for Protection of Patient Confidentiality of Patient Confidentiality
F Physicians passwords are issued F Physicians passwords are issued

by the Executive Directors office by the Executive Directors office when the physician is given hospital when the physician is given hospital credentials. credentials.

Individuals who have access to the Beth Israel Deaconess computerized patient information system can obtain records pertaining to the care and treatment hospital patients. Under Massachusetts law and the hospitals patient confidentiality policy, such records are confidential. We ask you to sign the following agreement. Press <Enter>

Measures in Use for Protection Measures in Use for Protection of Patient Confidentiality of Patient Confidentiality

F Terminals are frozen if illegal F Terminals are frozen if illegal

passwords are entered a few times. passwords are entered a few times.

Measures in Use for Protection of Measures in Use for Protection of Patient Confidentiality Patient Confidentiality

F Users are automatically signed off after F Users are automatically signed off after

a time-out period of approximately five a time-out period of approximately five minutes. minutes.

Measures in Use for Protection Measures in Use for Protection of Patient Confidentiality of Patient Confidentiality

F Access from home by telephone F Access from home by telephone

dial-up requires a second dial-up requires a second password. password.

Measures in Use for Protection Measures in Use for Protection of Patient Confidentiality of Patient Confidentiality
F The computer system stores each F The computer system stores each

access to patient information access to patient information indexed by person, professional indexed by person, professional role (staff doctor, nurse, resident, role (staff doctor, nurse, resident, student, other), location, type of student, other), location, type of information retrieved, date, and information retrieved, date, and time. time.

Measures in Use for Protection Measures in Use for Protection of Patient Confidentiality of Patient Confidentiality

F All patients (and their doctors) can F All patients (and their doctors) can

request a list of persons who have request a list of persons who have looked at their records. looked at their records.

Measures in Use for Protection Measures in Use for Protection of Patient Confidentiality of Patient Confidentiality
F Employees who use the computer F Employees who use the computer

system have an option under system have an option under Utilities that displays the names of Utilities that displays the names of persons who have looked at their persons who have looked at their electronic record. electronic record.

Utility Options Utility Options

Telephone Directory Telephone Directory Doctors Office Directory Doctors Office Directory View Lookups of Own File View Lookups of Own File How to use the Computer Terminal How to use the Computer Terminal

462 462 182 182 176 176 46 46

Measures in Use for Protection Measures in Use for Protection of Patient Confidentiality of Patient Confidentiality
F Terminals automatically display F Terminals automatically display

confidentiality warnings if a user confidentiality warnings if a user looks at a record of a VIP. looks at a record of a VIP. F Terminals randomly display F Terminals randomly display confidentiality warnings from time confidentiality warnings from time to time for all patients. to time for all patients.

Beth Israel Deaconess Patient Lookup Beth Israel Deaconess Patient Lookup Tues Mar 20, 2001 3:29 pm Tues Mar 20, 2001 3:29 pm --------------------------------------------------------------------------------------------------------------------------------------------------------End response by pressing return key. For help type ? End response by pressing return key. For help type ? Patient ID: Townsend,Minnette Patient ID: Townsend,Minnette 9999999 Paxton,Minnette 04/21/03 F 97 111-11-1111 9999999 Paxton,Minnette 04/21/03 F 97 111-11-1111 (Access Restricted) (Access Restricted) Arthur Marguetite Richard M Townsend Arthur Marguetite Richard M Townsend OK? Y // OK? Y // To protect each patients confidentiality only those who are To protect each patients confidentiality only those who are responsible for a patients care should use this option. We record responsible for a patients care should use this option. We record the identity of each user of patient lookup and will give this the identity of each user of patient lookup and will give this information to the patient or the patients physician upon request. information to the patient or the patients physician upon request. Type Yes to proceed, otherwise press return. N// Type Yes to proceed, otherwise press return. N//

In the Hands of Strangers In the Hands of Strangers


For purposes of reimbursement, hospitals For purposes of reimbursement, hospitals and clinics are now required to send and clinics are now required to send confidential clinical information, linked to confidential clinical information, linked to charges, to a broad array of third-party charges, to a broad array of third-party payers - - strangers who are beyond the payers - - strangers who are beyond the control of the hospital, clinic, doctor, or control of the hospital, clinic, doctor, or patients. Are they to be trusted? patients. Are they to be trusted?