Bringing Clinical Information to the Bedside with the World Wide Web

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Bringing Clinical Information to the Bedside with
the World Wide Web

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

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First Admission August, 1983

• In August, 1983, a 50 year old male presented to
  the St. Vincents 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.

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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.

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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

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What Happened?

• The surgeons didnt know to follow up
• The pathologists assumed someone would read their
  report
• No one was making sure that the ball didnt get
  dropped

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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

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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

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Volume

• No data are deleted
• 100 K bytes / patient
• 100 K patients / year
• 10 Gigabytes / year

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CIS Daily Inquiries (weekdays)
March '97
7547
2046
2022
Inquiries/day
1114
700
639
559
514
396
104
LAB
RAD
DEM
PATH
Adm
Disch
CAR
Op.
Phar
Other
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Physician Use
Clinical Information System Utilization Over Time
Peak vs. Other hours
16000
14000
Peak (2-5pm)
Normal (8am-2pm)
12000
Low (midnight to 8am)
10000
of screens/hour
8000
6000
4000
2000
0
1990
Sept
1991
Sept
1992
Sept
1993
Sept
1994
Sept
1995
Sept
1996
Sept
1997
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Physician Use
CIS Utilization
House Staff vs. Attendings
March 1997
100
90
80
70
60
House
officers
using CIS System
50
Attendings
40
30
20
10
0
MED
NEU
OBG
ORT
PED
PSY
SUR
URO
OTHER
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Clinical MLMs Alerts
SUBJECT
PERCENT
VIEWINGS /
EVENTS /
NUMBER OF
VIEWED
EVENT
MONTH
MLMs
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
3
newborn with HBV positive
55.0
1.9
12.5
2
mother
hypokalemia and diuretic
48.0
1.6
66
2
use
renal failure and
41.7
1.6
56
2
aminoglycoside use
renal failure and NSAID use
34.8
1.8
139
2
new anemia
32.4
2.1
430.7
1
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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

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Things You Can Do On the Web

• Read a newspaper
• Buy groceries
• Banking
• Trade stocks
• Track your Fed Ex package
• Get health information

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Health Information You Can Get

• Medline citations
• Drug advertisements
• Quack therapies
• Viagra prescriptions

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Health Information You Cant Get

• Your cholesterol level
• Your mammogram report
• A list of your current medications
• Advice from your doctor

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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

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PatCIS An Experiment with Patient Access

• Funded by the US National Library of Medince
• Data entry
• Data review
• Education
• Advice
• Infobuttons

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Potential Areas of Expansion

• Lab test interpretation
• Pap smear infobutton
• Medication lists
• Advance directives

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Addressing the Challenges

• Web access to records
• Security and confidentiality issues
• Political issues
• Ethical issues

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Ethical Issues

• Discovery without supervision
• Misunderstanding and worry
• Misunderstanding and complacency
• Patient-clinician communications
• better
• shorter
• worse
• longer

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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

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