Cyber

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.

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.

F The response time of the computer F The response time of the computer
should be rapid. should be rapid.

F The computer should be reliable F The computer should be reliable
and accurate. and accurate.

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.

F There should be a common registry F There should be a common registry
for all patients. for all patients.

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
Advice and consultation Advice and consultation
Clinical Use
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
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
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
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
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
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
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
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
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
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
-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
-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)
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
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
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
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.
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;
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;
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;
If the cybermedicine programs offer If the cybermedicine programs offer ready access to current, reliable ready access to current, reliable medical literature; medical literature;
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;
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,
And if the cybermedicine programs And if the cybermedicine programs have educational value, have educational value,
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 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.
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...
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)
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
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
use PaperChase to search for use PaperChase to search for related articles in the medical related articles in the medical literature literature
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 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 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.
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>
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.
F Access from home by telephone F Access from home by telephone
dial-up requires a second dial-up requires a second password. password.
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.
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.
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
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?

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Cybermedicine

Seven Principles of Clinical Computing

Seven Principles of Clinical Computing

Seven Principles of Clinical Computing

should be rapid. should be rapid.

Seven Principles of Clinical Computing

and accurate. and accurate.

Seven Principles of Clinical Computing

Seven Principles of Clinical Computing

for all patients. for all patients.

Seven Principles of Clinical Computing

00000000 Doe, John 00000000 Doe, John

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

00000000 Med *** Current Medications

Acetaminophen Bisacodyl Glotzers Solution Nystatin Prochorperazine

Acid-Base Evaluation Acid-Base Evaluation

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

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

Drug Information Drug Information

For Prozac For Prozac

Clinical Formulas Clinical Formulas

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

Please choose and option: Please choose and option:

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

Year 1999 Year 1999

Alerts and reminders Alerts and reminders

Clinicians Option: Clinicians Option:

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

Standard/Universal Precautions Standard/Universal Precautions

To quit <tab> To quit <tab>

To continue <enter> To continue <enter>

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

Reaction to Computer Interview Reaction to Computer Interview

Time About Right

Nursing Option Nursing Option

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

Inpatient Lookups Inpatient Lookups

Outpatient Lookups Outpatient Lookups

Use of Patient Lookup Use of Patient Lookup

Electronic Mailbox Electronic Mailbox

Effect on Work Effect on Work

4 13 88 204 236 545

E-mail Questionnaire Results E-mail Questionnaire Results

medical care medical care

F Indirect Evidence F Indirect Evidence

F Indirect Evidence F Indirect Evidence

F Direct Evidence F Direct Evidence

Clinician Response Time

F Direct Evidence F Direct Evidence

F Direct Evidence F Direct Evidence

F ERRORS IN MEDICINE F ERRORS IN MEDICINE

F Errors in Medicine F Errors in Medicine

F Errors in Medicine F Errors in Medicine

F Errors in Medicine F Errors in Medicine

F Errors in Medicine F Errors in Medicine

F Errors in Medicine F Errors in Medicine

F Errors in Medicine F Errors in Medicine

F Errors in Medicine F Errors in Medicine

F Errors in Medicine F Errors in Medicine

F Errors in Medicine F Errors in Medicine

F Errors in Medicine F Errors in Medicine

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