Cybermedicine

1
Cybermedicine

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

2
My Ideal Interactive Program for Patients

• The program should be medically sound

3
My Ideal Interactive Program for Patients

• The program should be medically sound
• The program should be easy to use

4
My Ideal Interactive Program for Patients

• The program should be medically sound
• The program should be easy to use
• The program should be truly interactive

5
My Ideal Interactive Program for Patients

• The program should be medically sound
• The program should be easy to use
• The program should be truly interactive
• The program should be of immediate benefit

6
My Ideal Interactive Program for Patients

• The program should be medically sound
• The program should be easy to use
• The program should be truly interactive
• The program should be of immediate benefit
• The patient should be in charge

7
My Ideal Interactive Program for Patients

• The program should be medically sound
• The program should be easy to use
• The program should be truly interactive
• The program should be of immediate benefit
• The patient should be in charge
• Confidentiality should be protected

8
My Ideal Interactive Program for Patients

• The program should be medically sound
• The program should be easy to use
• The program should be truly interactive
• The program should be of immediate benefit
• The patient should be in charge
• Confidentiality should be protected
• The program should be readily available to all

9
My Ideal Interactive Program for Patients

• The program should be medically sound
• The program should be easy to use
• The program should be truly interactive
• The program should be of immediate benefit
• The patient should be in charge
• Confidentiality should be protected
• The program should be readily available to all
• The computer should be fast and reliable

10
My Ideal Interactive Program for Patients

• The program should be medically sound
• The program should be easy to use
• The program should be truly interactive
• The program should be of immediate benefit
• The patient should be in charge
• Confidentiality should be protected
• The program should be readily available to all
• The computer should be fast and reliable
• The program should be subjected to formal study

11
Patient-Computer Dialogue

• Urinary Tract Infection Program

12
Patient-Computer Dialogue

• Teaching program for use of the computer (also
  serves to ascertain mental status)

13
Patient-Computer Dialogue

• Teaching program for use of the computer
• General medical history, conditions for referral,
  and referral if indicated

14
Patient-Computer Dialogue

• Teaching program for use of the computer
• General medical history, conditions for referral,
  and referral if indicated
• History referable to urinary tract infection

15
Patient-Computer Dialogue

• Teaching program for use of the computer
• General medical history, conditions for referral,
  and referral if indicated
• History referable to urinary tract infection
• Discussion of therapy

16
Patient-Computer Dialogue

• Teaching program for use of the computer
• General medical history, conditions for referral,
  and referral if indicated
• History referable to urinary tract infection
• Discussion of therapy
• Patients Choice about treatment

17
Patient-Computer Dialogue

• Teaching program for use of the computer
• General medical history, conditions for referral,
  and referral if indicated
• History referable to urinary tract infection
• Discussion of therapy
• Patients Choice about treatment
• Therapy

18
Patient-Computer Dialogue

• Teaching program for use of the computer
• General medical history, conditions for referral,
  and referral if indicated
• History referable to urinary tract infection
• Discussion of therapy
• Patients Choice about treatment
• Therapy
• Return Visit

19
Patient-Computer Dialogue

• After mastery of the keyboard, the program offers
  a bit of reinforcement,
• e.g. You have a nice touch with the keys.

20
Patient-Computer Dialogue

• If it is OK with you, we would now like to ask a
  few questions about urinary symptoms...

21
Patient-Computer Dialogue

• Are you bothered by pain or burning when you
  urinate?
• 1.Yes
• 2. No
• 3. Maybe ( dont know)
• 4. Dont understand
• 5. Skip it

22
Patient-Computer Dialogue

• Of these 1. How well does the medicine work?
  2. How much does it cost?
• 3. How safe is it?
• 4. How often must it be taken?
• 5. Is it a pill or an injection?
• 6. Can I get well without it?
• Which is most important to you 1

23
Patient-Computer Dialogue

• Of these 1. How well does the medicine work?
  2. How much does it cost?
• 3. How safe is it?
• 4. How often must it be taken?
• 5. Is it a pill or an injection?
• 6. Can I get well without it?
• Which is most important to you 1
• and which is least important 5

24
Patient-Computer Dialogue

• You indicated that knowing how well sulfa works
  is perhaps most important to you...
• Lets consider this first.

25
Patient-Computer Dialogue

• Before deciding about sulfa, would you like to go
  over anything again?
• 1. Yes
• 2. No
• 3. Maybe ( dont know)
• 4. Dont understand
• 5. Skip it

26
Patient-Computer Dialogue

• Very well then...would you like to
• 1. Take sulfa
• 2. Take nothing
• 3. Consider another medicine
• 4. Uncertain (cant decide)

27
Patient-Computer Dialogue

• It seems that you took some extra time with your
  answer. Does this mean that youve been
• 1. Thinking it over and feel youve made
  the right choice?
• 2. Trying to get things clear but
  arent sure about your choice?

28
Patient-Computer Dialogue

• We hope its OK then, to ask again what is your
  decision?
• 1. Uncertain (cant decide)
• 2. Consider another medicine
• 3. Take nothing
• 4. Take sulfa

29
Patients Reaction to the Computer

• How has it been here at the computer?
• Time well spent 35
• Not worth the time 0
• Not sure 4

30
Patients Reaction to the Computer

• Was the computer respectful?
• Yes 36
• No 0
• Maybe 0
• Dont understand 1
• Skip it 2

31
Patients Reaction to the Computer

• How has it been to decide for yourself about
  taking sulfa?
• A good thing 29
• Better left up to someone else 1
• No preference either way 2
• Not sure 2

32
Patient-Computer Dialogue

• A Computer-Based Health Care Interview for
  Hospital Personnel

33
The Seven Health-Related Sections of the Interview

• General medical history

34
The Seven Health-Related Sections of the Interview

• General medical history
• Nutrition history

35
The Seven Health-Related Sections of the Interview

• General medical history
• Nutrition history
• Exercise patterns

36
The Seven Health-Related Sections of the Interview

• General medical history
• Nutrition history
• Exercise patterns
• Habits

37
The Seven Health-Related Sections of the Interview

• General medical history
• Nutrition history
• Exercise patterns
• Habits
• Safety

38
The Seven Health-Related Sections of the Interview

• General medical history
• Nutrition history
• Exercise patterns
• Habits
• Safety
• Environment

39
The Seven Health-Related Sections of the Interview

• General medical history
• Nutrition history
• Exercise patterns
• Habits
• Safety
• Environment
• Stress

40
Stress

• In the PAST MONTH have you felt sad, discouraged
  or hopeless?
• 1. Yes
• 2. No
• 3. Maybe
• 4. Dont understand
• 5. Skip it
• Answer 1

41
Stress

• In the PAST MONTH has life sometimes seemed as if
  its not worth living?
• 1. Yes
• 2. No
• 3. Maybe
• 4. Dont understand
• 5. Skip it
• Answer 1

42
Stress

• When life seems like its not worth living, its
  often helpful to speak to someone about these
  feelings.
• ltENTERgt

43
Stress

• There are several places where you could call at
  any time to speak in confidence about these
  feelings.
• ltENTERgt

44
Stress

• Help is available any time day or night through
  the
• Employee Assistance Program - [phone]
• Samaritans - [phone]
• Or you can always contact the Emergency Room
  (Ext. 3337)
• Please be assured that whatever you say will be
  kept confidential

45
Stress

• Would you like to discuss this when you visit
  with your employee nurse?
• 1. Yes
• 2. No
• 3. Maybe
• 4. Dont understand
• 5. Skip it
• Answer 1

46
Stress

• You will be receiving a printed summary of this
  interview at that visit.
• Would it be ok to indicate on your summary that
  you would like to discuss this issue?
• 1. Yes
• 2. No
• Answer 2

47
Stress

• Thats fine, but please feel free to talk about
  it at your visit.
• ltENTERgt

48
Type of Work

• Professional 945
• Clerical 409
• Technical 225
• Managerial 120
• Service workers 48
• Other 162
• Skip it 28
• Total 1937

49
Age Distribution

• lt20 43
• 20-29 1006
• 30-39 626
• 40-49 192
• 50-59 52
• 60-69 17
• 70 1
• Total 1937

50
Sex Distribution

• Males 530
• Females 1407
• Total 1937

51
In the past month have you felt sad, discouraged,
or hopeless?

• Yes 811 (42)
• No 890 (46)
• Maybe 190 (10)
• Dont understand 12 (1)
• Skip it 34 (2)

52
In the past month has life sometimes seemed like
its not worth living?

• Yes 106 (6)
• No 812 (42)
• Maybe 57 (3)
• Dont understand 3 (0)
• Skip it 33 (2)

53
Health-Related Program Requests

• Fitness Center 1385
• Stress Reduction 724
• Time Management 457
• Low-Back Protection 260
• Smoking Cessation 126
• Total 2952

54
Employees Assessment
100
80
Percentage of Employees
60
40
20
0
Worthwhile Interesting
Understandable
55
PreferenceComputer vs. Doctor or Nurse
56
Revelation in the Absence of aFace-to-Face
Encounter

• Confessional
• Psychoanalysis
• Computer-assisted soliloquy
• Patient-computer dialogue

57
Improved Alcohol Screening
Interview self-reported vs.
clinician-documented alcohol use were
compared for 100 initial visits

• Computer interview, but not provider note
  14
• Provider note, but not computer interview
  0
• Computer interview and provider note
  80
• Computer interview, but ? provider note 6

58
Discrepant Case 1

• MD note
• uses alcohol socially
• Interview Self-Report
• frequency 2-3/week, 3-4/day, 6 drinks
  monthly, blackouts monthly

59
Discrepant Case 2

• MD note
• occasional ETOH
• Interview Self-Report
• had drinking problem in the past, abstinent
  now

60
Reaction of Patients to Computer Interviewing
Pa t i en t s Que s t i oned
61
Did the computer sometimes ask more than you
wanted to tell?
Did you sometimes want to tell the computer more
than it asked?
Yes
No
Uncertain
62
Response Latency vs. Age
MEAN RESPONSE LATENCY (seconds)
No Responses Yes Responses All Responses

Age (years) Sample Size

265 88 36
36 17 16
63
Cybermedicine for the Clinician

• Registration
• Laboratories
• Clinical Departments
• Finance
• Clinical use

64
Clinical Use

• Provides clinical information upon request
• Gives support with decisions
• Assists with communication
• Assists with clinical practice
• Assists with education

65
Clinical Use

• Provides clinical information upon request

66

• 00000000 Doe, John 3/21/70
  31M
• 1. All Labs 11. Result Over Time
• 2. Blood Bank 12. Microbiology
• 3. Blood Gas 13. Neurophysiology
• 4. Cardiology 14. Online Medical Record
• 5. Chemistry 15. Outside/Lexington Lab
• 6. Cytogenics 16. Pharmacy
• 7. Cytology 17. Pulmonary Function
• 8. Demographics 18. Radiology
• 9. Electrocardiograms 19. Clinical Pathology
• 10. Hematology 20.
  Urinalysis

67
00000000 Admitted
03/13 Room 12R-1275
Med Current Medications Medication
Dose Route Schedule Start
(-End) ----------------------------------- IVs
and injectibles ----------------------------------
--------- Cefazolin 2 GM IV PIGGY
QBH 08/16
--------------------------------------- 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-------------------------
---------------- Acetaminophen 650 MG
PO TAB FS Q4H24HR
08/13 Bisacodyl 10 ML PR
SUPP FS PRN 08/18 Glotzers Solution
100 ML IRR IRR LC
08/13 Nystatin 6000 UNITS
PO SUSP LC PRN QID 08/13 Prochorperazi
ne 10 MG PO TAB PRN Q6H
08/13 Enter for next page, _to backup, to
quit, or a page number
68
Clinical Use

• Gives support with decisions
• Advice and consultation
• Acid-Base Evaluation
• Drug Information
• Clinical Formulas
• HIV ProtoCall
• Withdrawal of therapy

69
Clinical Use

• Gives support with decisions
• Advice and consultation
• Bibliographic retrieval (PaperChase)

70
Clinical Use

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

71

• .
• C l i n Q u e r y Sat Mar 17,
  2001 307 pm
• ClinQuery covers 495,448 admissions from 1984
  through 01/31/01.
• Please enter the year or range of years (e.g.
  85-90) you are going to search.
• Year(s) 1999

72

• .
• C l i n Q u e r y Year 99 Sat Mar
  17, 2001 309 pm
• Look For age
• 1. Admin/Demography 6. Radiology
• 2. Laboratory Results 7. Cardiac Cath
• 3. Blood Bank 8. Outpatient
• 4. Medications 9. Diagnosis/procedure
• 5. Surgical Pathology 10. DRG
• Or enter ? for more information

73

• C l i n Q u e r y Year 1999
  Sat Mar 17, 2001 309 pm
• Age
• Choice Values Admissions
• 1) lt--- .9 5145
• 2) 1.0-9.9 1
• 3) 10.0-17.9
  91
• 4) 18.0-19.9
  261
• 5) 20.0-29.9
  2723
• 6) 30.0-39.9
  5614
• 7) 40.0-49.9
  3427
• 8) 50.0-59.9
  3602
• 9) 60.0-64.9
  1847
• A) 65.0-69.9
  2009
  
• B) 70.0-79.9
  4278
• C) 80.0 ---gt
  3961
• Choices

74
Clinical Use

• Gives support with decisions
• Advice and consultation
• Bibliographic retrieval (PaperChase)
• Searching the clinical database
• Alerts and reminders

75
Clinical Use

• Assists with communication

76
E-Mail
Inquire If Message Read
Read Mail Write Message Retract Mail
Inquire If Message Read
Personal Menu Help
77
E-Mail
Retract Mail
Read Mail Write Message
Retract Mail
Inquire If Message Read Personal Menu Help
78
Clinical Use

• Assists with clinical practice

79

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

80
Clinicians Options

• Confidential counseling for house staff

81

• ..
• House Staff Support and Consultation
• From time to time a House Officer or Fellow
  may have a personal matter that motivates him or
  her to seek professional counseling.
• Psychiatric consultation and referral that is
  confidential and independent of administrative
  reporting is readily available.
• Please feel free to call or page any of the
  psychiatrists listed on the next screen.
• Your call will remain confidential.

82
House Staff Support and Consultation

• Academic Year Accesses
• 1995 388
• 1996 380
• 1997 382
• 1998 424
• 1999 330
• 2000 287

83
Clinical Use

• Assists with education

84
Clinical Use

• Assists with education
• -ECG case of the week

85

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

86
(No Transcript)
87
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.
88
Evaluating Cybermedicine

• Use of the system by voluntary users

89
Beth Israel Deaconess Use of Patient
LookupInpatients and Outpatients
90
Use of Patient Lookup According to Type of
Inquiry at Beth Israel Deaconess, April 27-May
3, 1998
91
Passwords to the CCC CybermedicineSystem at Beth
Israel Deaconess

• (winter 2000/2001)
• Staff Physicians 1,034
• Nurses 1,983
• Clinical Fellows 258
• House Officers 630
• Medical Students 395

92
Use of Patient Lookup
93

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

94

Evaluating Cybermedicine

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

95
Effect on Work
96
Evaluating Cybermedicine

• Use of the system by voluntary users
• Attitude toward the system
• Effect of the system on the quality of medical
  care

97

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

98

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

99

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

100
Clinician Response Time
Reminders
Alerts
(days)
101

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

102

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

103

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

104

• Errors in Medicine
• The extent of the problem is debatable
• but
• Most would agree there is a problem

105

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

106

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

107

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

108

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

109

• Errors in Medicine
• If the cybermedicine programs offer advice and
  consultation, when requested, about diagnosis and
  treatment

110

• Errors in Medicine
• If the cybermedicine programs offer ready access
  to current, reliable medical literature

111

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

112

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

113

• Errors in Medicine
• And if the cybermedicine programs have
  educational value,

114

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

115

Evaluating Cybermedicine

• Use of the system by voluntary users
• Attitude toward the system
• Effect of the system on the quality of medical
  care
• The Teaching Power of Cybermedicine

116

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

117

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

118

• Teaching
• the student can request computer-based
  consultation on diagnosis and treatment (data
  from the labs are transferred to the consultation
  programs automatically)

119

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

120

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

121

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

122

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

123

Evaluating Cybermedicine

• Use of the system by voluntary users
• Attitude toward the system
• Effect of the system on the quality of medical
  care
• The Teaching Power of Cybermedicine
• Effect of the System on Hospital Finances

124
Effect of Cybermedicine on Finances at Brigham
and Womens Hospital

• Receivables dropped from 100 days in 1983 to 59
  days in 1988
• Outstanding debts in the outpatient clinics
  clinics were reduced by more than 6 million
  while cash collected from revenues increased by
  45

125
Time needed to collect bills in relation to use
of computing programs at Brigham Womens
126
Effect of Cybermedicine on Finances at Brigham
and Womens Hospital

• Order Entry System costs the hospital about 2
  million a year to maintain
• Order Entry System saves about 5 million a year
  in accounts payable
• Net Gain approximately 3 million a year

127
Time needed to collect bills in relation to use
of computing programs at Beth Israel
128

Evaluating Cybermedicine

• Use of the system by voluntary users
• Attitude toward the system
• Effect of the system on the quality of medical
  care
• The Teaching Power of Cybermedicine
• Effect of the System on Hospital Finances
• Cost of the System

129
Cost of Cybermedicine at Brigham and Womens
Hospital

• Approximately 2 of the annual operating budget
  (1983 1989)

130
Cost of Cybermedicine at Beth Israel
Hospital

• Approximately 1.5 of the annual operating budget
  (1978-1995)
• (Most American hospitals spend between 2 and 6
  for computing, which is mostly financial and
  administrative in function.)

131

Confidentiality
132
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133
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