Bringing Clinical Information to the Bedside with the World

Wide Web

James J. Cimino, M.D.Departments of Medicine and Medical Informatics

Columbia University

First Admission: August, 1983

In August, 1983, a 50 year old male presented to the St. Vincent’s Hospital (NY) emergency room with a scalp laceration due to a falling paint can. The wound was cleaned and sutured, and the patient was given a follow up appointment for surgery clinic. Two weeks later, the patient was seen at the scheduled clinic visit and was found to have delayed healing of one portion of the wound. After several weekly visits, the poorly-healing area was excised and the wound was closed. The patient had a good result and was discharged from further follow up.

Second Admission - March, 1984

The patient was brought to the emergency room for recent increasing lethargy. Laboratory evaluation was remarkable only for a calcium of 17 mg/dl. The patient was treated aggressively with hydration and diuretics, but expired shortly after admission. A diagnostic report was received.

Prologue as Epilogue

The pathology report from the wound revision the previous September included the following phrase:

“Metastatic adenocarcinoma of uncertain origin is noted at the tissue margins”

What Happened?

• The surgeons didn’t know to follow up

• The pathologists assumed someone would read their report

• No one was making sure that the ball didn’t get dropped

How Could Computers Help?

• The report would not fall through the cracks

• Route the report to the right person

• Generate an alert

• Check to see if someone read the report/alert

How Can the Web Help?

• Ubiquitous (bi-directional) access

• Bring together information from multiple systems

• Access to on-line health information resources

• Integration of information resources and clinical applications

MedicalEntities

Dictionary

PatientDatabase

Radiology

Pharmacy

LaboratoryEvent

Monitor

MedicalLogic

Modules

Billing &Financial

DatabaseInterface

Data Entry& Results Review

ResearchDatabases

Specialized Encoders MedLEE

Volume

• No data are deleted

• 100 K bytes / patient

• 100 K patients / year

• 10 Gigabytes / year

CIS Daily Inquiries (weekdays)March '97

2022 2046

1114639 700 559 514

104396

7547

LAB RAD DEM PATH Adm Disch CAR Op. Phar Other

Inq

uir

ies/

day

Physician UseClinical Information System Utilization Over TimePeak vs. Other hours

0

2000

4000

6000

8000

10000

12000

14000

160001

99

0

Se

pt

19

91

Se

pt

19

92

Se

pt

19

93

Se

pt

19

94

Se

pt

19

95

Se

pt

19

96

Se

pt

19

97

# o

f sc

reen

s/h

ou

r

Peak (2-5pm)Normal (8am-2pm)Low (midnight to 8am)

Physician UseCIS UtilizationHouse Staff vs. Attendings

March 1997

0

10

20

30

40

50

60

70

80

90

100

MED NEU OBG ORT PED PSY SUR URO OTHER

% u

sin

g C

IS S

yste

m

Houseofficers

Attendings

Clinical MLMs: AlertsSUBJECT PERCENT

VIEWEDVIEWINGS /

EVENTEVENTS /MONTH

NUMBER OFMLMs

positive TB culture 73.5 7.5 34.3 1

creatinine rise 63.1 3.1 254.1 1

hypokalemia and digoxin use 57.5 2.1 87.1 3newborn with HBV positivemother

55.0 1.9 12.5 2

hypokalemia and diureticuse

48.0 1.6 66 2

renal failure andaminoglycoside use

41.7 1.6 56 2

renal failure and NSAID use 34.8 1.8 139 2

new anemia 32.4 2.1 430.7 1

WebCIS

• Web-based Clinical Information System

• For use by clinicians (doctors, nurses, students)

• Access to all data in the repository

• Access to on-line information resources

Things You Can Do On the Web

• Read a newspaper

• Buy groceries

• Banking

• Trade stocks

• Track your Fed Ex package

• Get health information

Health Information You Can Get

• Medline citations

• Drug advertisements

• Quack therapies

• Viagra prescriptions

Health Information You Can’t Get

• Your cholesterol level

• Your mammogram report

• A list of your current medications

• Advice from your doctor

Personal Health Information on the Web

• Access to your electronic medical record

• Ability to contribute to your medical record

• Relevant, reliable, understandable advice

• Fostering patient-clinician communication

PatCIS: An Experiment with Patient Access

• Funded by the US National Library of Medince

• Data entry

• Data review

• Education

• Advice

• “Infobuttons”

Potential Areas of Expansion

• Lab test interpretation

• Pap smear infobutton

• Medication lists

• Advance directives

Addressing the Challenges

• Web access to records

• Security and confidentiality issues

• Political issues

• Ethical issues

Ethical Issues

• Discovery without supervision

• Misunderstanding and worry

• Misunderstanding and complacency

• Patient-clinician communications– better– shorter– worse– longer

Conclusions

• Web access to clinical information is feasible for clinicians and patients

• The Web offers innovative ways to view data

• Integration of clinical systems and decision support tools is possible

• Infrastructure is crucial

• Cognitive issues are under study