Experience using a programmable rules engine to implement a complex medical protocol during order entry.
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WizOrder, Vanderbilt University Medical Center's (VUMC) clinician order entry system, is an excellent platform for delivering high-quality decision support to clinical end-users. A scripting language designed to make it easy for non-programmer domain experts to enter rules helps distribute the generation and maintenance of the knowledge-base necessary to drive effective decision support. Domain-experts have used this system to successfully implement relatively simple protocols. The VUMC Care Improvement Committee identified diagnosis of and treatment for suspected or confirmed deep venous thrombosis or pulmonary embolism as an area where decision-support could improve clinician compliance with established evidence-based protocols. The authors describe our experience with using our existing scripting system to implement decision support for a complex medical protocol. (+info)
ActiveGuidelines: integrating Web-based guidelines with computer-based patient records.
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Use of the World Wide Web provides an efficient means to disseminate guidelines, but integrating them into the workflow at the point of care remains elusive. We developed a method, ActiveGuidelines (AGL), of integrating web-based guidelines with computer-based patient record (CPR) systems. An ActiveGuideline is an HTML document containing special tags that are interpreted by a CPR as actions (e.g., medication order, test order, referral, patient instructions). In our usage scenario, the CPR automatically displays ActiveGuidelines relevant to the current patient context. After reviewing the guideline, the user selects recommended orders directly from the ActiveGuideline. The selected orders are automatically transmitted to the CPR and executed as regular orders. An ActiveGuideline editor facilitates easy conversion of existing HTML-formatted guidelines into ActiveGuidelines. We believe that integrating patient-specific ActiveGuidelines within a CPR system will improve utilization of clinical guidelines in routine patient care. (+info)
In our previous work, we proposed a domain-independent language to describe clinical guidelines and a graphical tool to acquire them. In this paper, we describe an approach to execute clinical guidelines. We propose a flexible execution engine that can be used in clinical decision support applications, and also for medical education, or for integrating guidelines into the clinical workflow. We also focus our attention on temporal issues in the execution of guidelines, including the treatment of composite, concurrent and/or cyclic actions. (+info)
From guideline modeling to guideline execution: defining guideline-based decision-support services.
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We describe our task-based approach to defining the guideline-based decision-support services that the EON system provides. We categorize uses of guidelines in patient-specific decision support into a set of generic tasks--making of decisions, specification of work to be performed, interpretation of data, setting of goals, and issuance of alert and reminders--that can be solved using various techniques. Our model includes constructs required for representing the knowledge used by these techniques. These constructs form a toolkit from which developers can select modeling solutions for guideline task. Based on the tasks and the guideline model, we define a guideline-execution architecture and a model of interactions between a decision-support server and clients that invoke services provided by the server. These services use generic interfaces derived from guideline tasks and their associated modeling constructs. We describe two implementations of these decision-support services and discuss how this work can be generalized. We argue that a well-defined specification of guideline-based decision-support services will facilitate sharing of tools that implement computable clinical guidelines. (+info)
Computers in imaging and health care: now and in the future.
(45/500)
Early picture archiving and communication systems (PACS) were characterized by the use of very expensive hardware devices, cumbersome display stations, duplication of database content, lack of interfaces to other clinical information systems, and immaturity in their understanding of the folder manager concepts and workflow reengineering. They were implemented historically at large academic medical centers by biomedical engineers and imaging informaticists. PACS were nonstandard, home-grown projects with mixed clinical acceptance. However, they clearly showed the great potential for PACS and filmless medical imaging. Filmless radiology is a reality today. The advent of efficient softcopy display of images provides a means for dealing with the ever-increasing number of studies and number of images per study. Computer power has increased, and archival storage cost has decreased to the extent that the economics of PACS is justifiable with respect to film. Network bandwidths have increased to allow large studies of many megabytes to arrive at display stations within seconds of examination completion. PACS vendors have recognized the need for efficient workflow and have built systems with intelligence in the management of patient data. Close integration with the hospital information system (HIS)-radiology information system (RIS) is critical for system functionality. Successful implementation of PACS requires integration or interoperation with hospital and radiology information systems. Besides the economic advantages, secure rapid access to all clinical information on patients, including imaging studies, anytime and anywhere, enhances the quality of patient care, although it is difficult to quantify. Medical image management systems are maturing, providing access outside of the radiology department to images and clinical information throughout the hospital or the enterprise via the Internet. Small and medium-sized community hospitals, private practices, and outpatient centers in rural areas will begin realizing the benefits of PACS already realized by the large tertiary care academic medical centers and research institutions. Hand-held devices and the Worldwide Web are going to change the way people communicate and do business. The impact on health care will be huge, including radiology. Computer-aided diagnosis, decision support tools, virtual imaging, and guidance systems will transform our practice as value-added applications utilizing the technologies pushed by PACS development efforts. Outcomes data and the electronic medical record (EMR) will drive our interactions with referring physicians and we expect the radiologist to become the informaticist, a new version of the medical management consultant. (+info)
Computer-supported detection of M-components and evaluation of immunoglobulins after capillary electrophoresis.
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BACKGROUND: Electrophoresis of serum samples allows detection of monoclonal gammopathies indicative of multiple myeloma, Waldenstrom macroglobulinemia, monoclonal gammopathy of undetermined significance, and amyloidosis. Present methods of high-resolution agarose gel electrophoresis (HRAGE) and immunofixation electrophoresis (IFE) are manual and labor-intensive. Capillary zone electrophoresis (CZE) allows rapid automated protein separation and produces digital absorbance data, appropriate as input for a computerized decision support system. METHODS: Using the Beckman Paragon CZE 2000 instrument, we analyzed 711 routine clinical samples, including 95 monoclonal components (MCs) and 9 cases of Bence Jones myeloma, in both the CZE and HRAGE systems. Mathematical algorithms developed for the detection of monoclonal immunoglobulins (MCs) in the gamma- and ss-regions of the electropherogram were tested on the entire material. Additional algorithms evaluating oligoclonality and polyclonal concentrations of immunoglobulins were also tested. RESULTS: CZE electropherograms corresponded well with HRAGE. Only one IgG MC of 1 g/L, visible on HRAGE, was not visible after CZE. Algorithms detected 94 of 95 MCs (98.9%) and 100% of those visible after CZE. Of 607 samples lacking an MC on HRAGE, only 3 were identified by the algorithms (specificity, 99%). Algorithms evaluating total gammaglobulinemia and oligoclonality also identified several cases of Bence Jones myeloma. CONCLUSIONS: The use of capillary electrophoresis provides a modern, rapid, and cost-effective method of analyzing serum proteins. The additional option of computerized decision support, which provides rapid and standardized interpretations, should increase the clinical availability and usefulness of protein analyses in the future. (+info)
Cardiac output-based versus empirically programmed AV interval--how different are they?
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AIMS: To compare empirically programmed and cardiac output-based programming of atrioventricular (AV) interval in patients with dual chamber pacemakers. METHODS AND RESULTS: In 19 patients with implanted dual chamber pacemakers due to AV block but otherwise normal hearts, cardiac output was assessed using an impedance cardiography device. In all patients, the AV interval had been previously programmed empirically by an experienced cardiologist. Cardiac output was estimated at AV intervals from 50 to 250 ms during VDD pacing. AV intervals adjusted by serial cardiac output estimations caused a rise in cardiac output in 84% of patients. The maximal achievable cardiac output was greater by 12% +/- 8% (range 0-32%), P < 0.001, than was observed with empirically programmed AV intervals. CONCLUSIONS: In patients with dual chamber pacemakers due to AV block and otherwise normal hearts, empirically selected AV intervals may lead to compromise of cardiac haemodynamics. Optimal AV intervals may be selected by serial cardiac output measurements. (+info)
Decision support for patients with early-stage breast cancer: effects of an interactive breast cancer CDROM on treatment decision, satisfaction, and quality of life.
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PURPOSE: To investigate the effects of the Interactive Breast Cancer CDROM as a decision aid for breast cancer patients with a choice between breast conserving therapy (BCT) and mastectomy (MT). PATIENTS AND METHODS: Consecutive patients with stage I and II breast cancer were enrolled. A quasi-experimental, longitudinal, and pretest/posttest design was used. Follow-up was scheduled 3 and 9 months after discharge from the hospital. Control patients (n = 88) received standard care (oral information and brochures). The CDROM was provided to patients in the experimental condition (n = 92) as a supplement to standard procedures. Outcome variables were treatment decision, satisfaction, and quality of life (QoL). RESULTS: No effect on treatment decision was found. CDROM patients expressed more general satisfaction with information at 3 and 9 months (95% confidence interval for the difference (d) between the means (d: 4.1 to 12.5 and 5.7 to 14.2 respectively). CDROM patients were also more satisfied with their treatment decision at 3 and at 9 months (d: 0.1 to 0.4; 0.2 to 0.5). Moreover, at 9 months, CDROM patients were more satisfied with breast cancer-specific information (d: 0.9 to 16.5), the decision-making process (d: 0.1 to 0.4), and communication (d: 0.2 to 11.0). At 3 and 9 months, a positive effect was found on general health (d: 0.2 to 14.5 and 0.3 to 15.0). Moreover, at 9 months, CDROM patients reported better physical functioning (d: 5.1 to 19.8), less pain (d: -17.9 to -4.5), and fewer arm symptoms (d: -14.1 to -0.5). CONCLUSION: The Interactive Breast Cancer CDROM improved decision making in patients with early-stage breast cancer with a choice between BCT and MT, as evaluated in terms of patients' satisfaction and QoL. (+info)