Information Technology in the Healthcare System of … Technology in the Healthcare System of the...

Information Technology in the Healthcare System of the Future

A Brief History of Cybermedicine

Information Technology in the Healthcare Information Technology in the Healthcare System of the FutureSystem of the Future

A Brief History of CybermedicineA Brief History of Cybermedicine

Warner V. Slack, M.D.Division of Clinical Computing

Harvard Medical SchoolBeth Israel Deaconess Medical Center

Warner V. Slack, M.D.Warner V. Slack, M.D.Division of Clinical ComputingDivision of Clinical Computing

Harvard Medical SchoolHarvard Medical SchoolBeth Israel Deaconess Medical CenterBeth Israel Deaconess Medical Center

Harvard-MIT Division of Health Sciences and TechnologyHST.921: Information Technology in the Health Care System of the Future, Spring 2007Course Director: Steven E. Locke, MD

Cybermedicine for the ClinicianCybermedicine for the ClinicianCybermedicine for the Clinician

Clinical UseClinical UseClinical Use

Assists with requests (order entry) Assists with requests (order entry) Assists with requests (order entry)


Assists with requests (order entry) Provides clinical information upon requestAssists with requests (order entry) Assists with requests (order entry) Provides clinical information upon requestProvides clinical information upon request

00000000 Paxton, Minnette 3/21/70 100F

1. All Labs 11. Result Over Time2. Blood Bank 12. Microbiology3. Blood Gas 13. Neurophysiology4. Cardiology 14. Online Medical Record5. Chemistry 15. Outside/Lexington Lab6. Cytogenics 16. Pharmacy7. Cytology 17. Pulmonary Function8. Demographics 18. Radiology9. Electrocardiograms 19. Clinical Pathology

10. Hematology 20. Urinalysis

0000000000000000 Paxton, Minnette 3/21/70 100FPaxton, Minnette 3/21/70 100F

1. All Labs 1. All Labs 11. Result Over Time11. Result Over Time2. Blood Bank 2. Blood Bank 12. Microbiology12. Microbiology3. Blood Gas3. Blood Gas 13. Neurophysiology13. Neurophysiology4. Cardiology4. Cardiology 14. Online Medical Record14. Online Medical Record5. Chemistry5. Chemistry 15. Outside/Lexington Lab15. Outside/Lexington Lab6. Cytogenics6. Cytogenics 16. Pharmacy16. Pharmacy7. Cytology7. Cytology 17. Pulmonary Function17. Pulmonary Function8. Demographics8. Demographics 18. Radiology18. Radiology9. Electrocardiograms 19. Clinical Pathology9. Electrocardiograms 19. Clinical Pathology

10. Hematology10. Hematology 20. Urinalysis20. Urinalysis


Assists with requests (order entry) Provides clinical information upon requestGives support with decisions

Assists with requests (order entry) Assists with requests (order entry) Provides clinical information upon requestProvides clinical information upon requestGives support with decisionsGives support with decisions


Gives support with decisions– Advice and consultationGives support with decisionsGives support with decisions–– Advice and consultationAdvice and consultation

Free Water Deficit or Sodium DeficitFree Water Deficit or Sodium Deficit

Free H20 Deficit = TBW Free H20 Deficit = TBW --TBW x (Desired Na/Measured Na)TBW x (Desired Na/Measured Na)NA Deficit = TBW x (Desired NA NA Deficit = TBW x (Desired NA -- Measured Na)Measured Na)

TBWTBW = WGT X [0.6 (Male) or 0.5 (Female)]= WGT X [0.6 (Male) or 0.5 (Female)]

Weight = lbs or kg Weight = lbs or kg Male or Female? Male or Female? Current Serum Na = Current Serum Na = mEqmEq/L/LDesired Na Desired Na = = mEqmEq/L/L

Free Water Deficit or Sodium DeficitFree Water Deficit or Sodium Deficit

Look at References?Look at References?

5757FemaleFemale160160140140

Free H20 Deficit = LitersFree H20 Deficit = LitersNotes:Notes:1) Correct about half of total deficit in first 24 hours1) Correct about half of total deficit in first 24 hours2) Correction rate should be 0.5 2) Correction rate should be 0.5 mEqmEq/L/hr (12 /L/hr (12 mEqmEq/day)/day)3) Recompile deficit frequently3) Recompile deficit frequently4) Add insensible fluid losses to computed values4) Add insensible fluid losses to computed values

NN

3.6


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

Gives support with decisionsGives support with decisions–– Advice and consultationAdvice and consultation–– Bibliographic retrieval (PaperChase)Bibliographic retrieval (PaperChase)


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

Gives support with decisionsGives support with decisions–– Advice and consultationAdvice and consultation–– Bibliographic retrieval (PaperChase)Bibliographic retrieval (PaperChase)–– Searching the clinical databaseSearching the clinical database

.

C l i n Q u e r y Sat Mar 17, 2001 3:07 pm

ClinQuery covers 495,448 admissions from 1984 through 2000.

Please enter the year or range of years (e.g. 85-90) you aregoing to search.

Year(s): 1999

..

C l i n Q u e r yC l i n Q u e r 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 2000.2000.

Please enter the year or range of years (e.g. 85Please enter the year or range of years (e.g. 85--90) you are 90) you are going to search.going to search.

Year(s): 1999Year(s): 1999

C l i n Q u e r y Year 1999 Sat Mar 17, 2001 3:09 pm

AgeChoice Values Admissions1) <--- .9 51452) 1.0-9.9 13) 10.0-17.9 914) 18.0-19.9 2615) 20.0-29.9 27236) 30.0-39.9 56147) 40.0-49.9 34278) 50.0-59.9 36029) 60.0-64.9 1847A) 65.0-69.9 2009 B) 70.0-79.9 4278C) 80.0 ---> 3961

Choices:

C l i n Q u e r yC l i n Q u e r y Year 1999 Sat Mar 17, 2001 3:09 pm Year 1999 Sat Mar 17, 2001 3:09 pm

AgeAgeChoiceChoice ValuesValues AdmissionsAdmissions1)1) <<------ .9.9 514551452)2) 1.01.0--9.99.9 113)3) 10.010.0--17.9 17.9 91914) 18.04) 18.0--19.9 26119.9 2615) 20.05) 20.0--29.9 272329.9 27236) 30.06) 30.0--39.9 561439.9 56147) 40.07) 40.0--49.9 342749.9 34278) 50.08) 50.0--59.9 360259.9 36029) 60.09) 60.0--64.9 184764.9 1847A) 65.0A) 65.0--69.9 2009 69.9 2009 B) 70.0B) 70.0--79.9 427879.9 4278C) 80.0 C) 80.0 ------> 3961> 3961

Choices:Choices:


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

Gives support with decisionsGives support with decisions–– Advice and consultationAdvice and consultation–– Bibliographic retrieval (PaperChase)Bibliographic retrieval (PaperChase)–– Searching the clinical databaseSearching the clinical database–– Alerts and remindersAlerts and reminders


Assists with requests (order entry) Provides clinical information upon requestGives support with decisionsAssists with communication

Assists with requests (order entry) Assists with requests (order entry) Provides clinical information upon requestProvides clinical information upon requestGives support with decisionsGives support with decisionsAssists with communicationAssists with communication


Assists with requests (order entry) Provides clinical information upon requestGives support with decisionsAssists with communicationAssists with clinical practice

Assists with requests (order entry) Assists with requests (order entry) Provides clinical information upon requestProvides clinical information upon requestGives support with decisionsGives support with decisionsAssists with communicationAssists with communicationAssists with clinical practiceAssists with clinical practice

Clinician’s Option:

1. Admissions or Labs by Service, Firm or Team2. Adverse Drug Reaction Reporting3. Cross Coverage Options4. Incomplete Medical Records5. Personal Patient Lookup6. Resident/Medical Student Log7. View Clinician’s Hospitalized Patients8. Confidential Counseling for House Staff

ClinicianClinician’’s Option:s Option:

1. Admissions or Labs by Service, Firm or Team1. Admissions or Labs by Service, Firm or Team2. Adverse Drug Reaction Reporting2. Adverse Drug Reaction Reporting3. Cross Coverage Options3. Cross Coverage Options4. Incomplete Medical Records4. Incomplete Medical Records5. Personal Patient Lookup5. Personal Patient Lookup6. Resident/Medical Student Log6. Resident/Medical Student Log7. View Clinician7. View Clinician’’s Hospitalized Patientss Hospitalized Patients8. Confidential Counseling for House Staff8. Confidential Counseling for House Staff

.. 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.

Choose option(s), or ‘A’ for All:

.. .. House Staff Support and ConsultationHouse Staff Support and Consultation

From time to time a House Officer or Fellow may have a personFrom time to time a House Officer or Fellow may have a personal matter that al matter that motivates him or her to seek professional counseling.motivates him or her to seek professional counseling.

Psychiatric consultation and referral that is confidential anPsychiatric consultation and referral that is confidential and independent of d independent of administrative reporting is readily available.administrative reporting is readily available.

Please feel free to call or page any of the psychiatrists lisPlease feel free to call or page any of the psychiatrists listed on the next ted on the next screen.screen.

Your call will remain confidential.Your call will remain confidential.

Choose option(s), or Choose option(s), or ‘‘AA’’ for All:for All:

Clinical UseClinical UseClinical UseAssists with requests (order entry) Provides clinical information upon requestGives support with decisionsAssists with communicationAssists with clinical practiceAssists with education

Assists with requests (order entry) Assists with requests (order entry) Provides clinical information upon requestProvides clinical information upon requestGives support with decisionsGives support with decisionsAssists with communicationAssists with communicationAssists with clinical practiceAssists with clinical practiceAssists with educationAssists with education

Instructional ProgramsLearning by DoingIn the tradition of John Dewey,

cybermedicine promotes learning in the context of caring for real patients.

Instructional ProgramsInstructional ProgramsLearning by DoingLearning by DoingIn the tradition of John Dewey, In the tradition of John Dewey,

cybermedicine promotes learning in cybermedicine promotes learning in the context of caring for real patients.the context of caring for real patients.

Evaluating CybermedicineEvaluating CybermedicineEvaluating Cybermedicine

Use of the system by voluntary usersUse of the system by voluntary usersUse of the system by voluntary users

Beth Israel Deaconess Use of Patient Lookup:Inpatients and Outpatients

Beth Israel Deaconess Use of Patient Lookup:Beth Israel Deaconess Use of Patient Lookup:Inpatients and OutpatientsInpatients and Outpatients

21,497

44,383

12,688

30,264 35,22927,707 34,614

27,023

13,229

010,00020,00030,00040,00050,00060,00070,00080,000

1984 1988 1992 1994 1998

Num

ber

of L

ooku

ps D

urin

g a

Typi

cal W

eek

Inpatient Lookups Outpatient Lookups

4,080

21,497

44,383

12,688

30,264 35,22927,707 34,614

27,023

13,229

010,00020,00030,00040,00050,00060,00070,00080,000

1984 1988 1992 1994 1998

Num

ber

of L

ooku

ps D

urin

g a

Typi

cal W

eek

Inpatient Lookups Outpatient Lookups

4,080

Inpatients Outpatients TotalAll Labs – Most Recent Results 17,018 10,044 27,062Demographics 3,277 9,420 12,697Chemistry 4,310 4,793 9,103Radiology 2,681 6,028 8,709Narrative Notes 1,163 3,893 5,056Cardiology 1,548 2,697 4,245Pathology 528 3,562 4,090Microbiology 1,990 1,001 2,991Hematology 1,014 1,786 2,800Blood Bank 743 439 1,182Pharmacy 753 282 1,035Neurophysiology 96 251 347Pulmonary Function 108 187 295Total 35,229 44,383 79,612

Inpatients Outpatients TotalAll Labs – Most Recent Results 17,018 10,044 27,062Demographics 3,277 9,420 12,697Chemistry 4,310 4,793 9,103Radiology 2,681 6,028 8,709Narrative Notes 1,163 3,893 5,056Cardiology 1,548 2,697 4,245Pathology 528 3,562 4,090Microbiology 1,990 1,001 2,991Hematology 1,014 1,786 2,800Blood Bank 743 439 1,182Pharmacy 753 282 1,035Neurophysiology 96 251 347Pulmonary Function 108 187 295Total 35,229 44,383 79,612

Use of Patient Lookup According to Type of Inquiry at Beth Israel Deaconess,

April 27-May 3, 1998

Use of Patient Lookup According to Type of Inquiry at Beth Israel Deaconess,

April 27-May 3, 1998

0 10 20 30 40 50Lookups Per User Per Week

Residents

Students

Fellows

Staff Doctors

Nurses

Others

0 10 20 30 40 50Lookups Per User Per Week

Residents

Students

Fellows

Staff Doctors

Nurses

Others

Use of Patient LookupUse of Patient Lookup

Use of the system by voluntary usersAttitude toward the systemUse of the system by voluntary usersUse of the system by voluntary usersAttitude toward the systemAttitude toward the system

Effect on WorkEffect on WorkEffect on Work

Accuracy Speed Ease Interest

Definitely worse 4 15 8 3

Probably worse 13 24 13 10

No difference 88 54 48 147Probably better 204 192 182 190

Definitely better 236 260 294 195

Total 545 545 545 545

Use of the system by voluntary usersAttitude toward the systemEducational power of the system

Use of the system by voluntary usersUse of the system by voluntary usersAttitude toward the systemAttitude toward the systemEducational power of the systemEducational power of the system

Use of the system by voluntary usersAttitude toward the systemEducational power of the system Effect of the system on quality of care

Use of the system by voluntary usersUse of the system by voluntary usersAttitude toward the systemAttitude toward the systemEducational power of the system Educational power of the system Effect of the system on quality of careEffect of the system on quality of care

Indirect EvidenceIndirect EvidenceIndirect Evidence

Indirect Evidence

Computing that offers information requested and advice on how to use it, with more ease, speed reliability, and accuracy than otherwise possible, is improving the quality of care.

Indirect EvidenceIndirect Evidence

Computing that offers information requested Computing that offers information requested and advice on how to use it, with more ease, and advice on how to use it, with more ease, speed reliability, and accuracy than otherwise speed reliability, and accuracy than otherwise possible, is improving the quality of care.possible, is improving the quality of care.

Direct EvidenceDirect EvidenceDirect Evidence

Direct Evidence

The time to act on important clinical events is significantly reduced when the physician is reminded or alerted by the computer of the need to act.

Direct EvidenceDirect Evidence

The time to act on important clinical events is The time to act on important clinical events is significantly reduced when the physician is significantly reduced when the physician is reminded or alerted by the computer of the reminded or alerted by the computer of the need to act.need to act.

Clinician Response TimeClinician Response Time

0 50 100 150 200 250 300 350 400 450 500

Intervention Control

RemindersReminders

AlertsAlerts

(days)(days)

Direct Evidence(Bates, Kuperman, Teich, et al: 1999)

Physicians at Brigham and Women’s Hospital, who now routinely use the computing system to request laboratory tests and prescribe medications…

Direct EvidenceDirect Evidence((Bates, Kuperman, Teich, et alBates, Kuperman, Teich, et al: : 19991999))

Physicians at Brigham and WomenPhysicians at Brigham and Women’’s s Hospital, who now routinely use the Hospital, who now routinely use the computing system to request laboratory computing system to request laboratory tests and prescribe medicationstests and prescribe medications……

Direct Evidence

…make significantly fewer errors.(serious errors in medications have been reduced by 55%)

Direct EvidenceDirect Evidence

……make significantly fewer errors.make significantly fewer errors.(serious errors in medications have been (serious errors in medications have been reduced by 55%)reduced by 55%)

Use of the system by voluntary usersAttitude toward the systemEducational power of the system Effect of the system on quality of careCost of the system

Use of the system by voluntary usersUse of the system by voluntary usersAttitude toward the systemAttitude toward the systemEducational power of the system Educational power of the system Effect of the system on quality of careEffect of the system on quality of careCost of the systemCost of the system

Use of the system by voluntary usersAttitude toward the systemEducational power of the system Effect of the system on quality of careCost of the systemEffect of system on hospital finances

Use of the system by voluntary usersUse of the system by voluntary usersAttitude toward the systemAttitude toward the systemEducational power of the system Educational power of the system Effect of the system on quality of careEffect of the system on quality of careCost of the systemCost of the systemEffect of system on hospital financesEffect of system on hospital finances

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

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 Hospitalcomputing programs at Beth Israel Hospital

0

10

20

30

40

50

60

70

80

TIM

E TO

CO

LLEC

T B

ILLS

(D

AYS

)

1976 1977 1978 1979 1980 1981 1982FISCAL YEAR

Registration Programs

Clinical Programs

Time needed to collect bills in relation to use of computing programs at Brigham & Women’s

Hospital

Time needed to collect bills in relation to use of Time needed to collect bills in relation to use of computing programs at Brigham & Womencomputing programs at Brigham & Women’’s s

HospitalHospital

0102030405060708090

100

TIM

E TO

CO

LLEC

T B

ILLS

(D

AYS

)

1982 1983 1984 1985 1986 1987 1988FISCAL YEAR

Registration Programs

Clinical ProgramsFinancial Programs


Cybermedicine programs such as those in

Kaiser Permanente, Univeri

Cybermedicine programs such as those inCybermedicine programs such as those in

Kaiser Permanente, Kaiser Permanente, UniveriUniveri


Cybermedicine programs such as those in theKaiser Permanente, University of Missouri, LDS,Regenstrief Institute, Columbia’s Presbyterian,Duke, and Vanderbilt, as well as BU, Tufts,MGH, Brigham and Women’s and BIDMChospitals, have proved to be highly useful inthe practice of medicine.

Cybermedicine programs such as those in theCybermedicine programs such as those in theKaiser Permanente, University of Missouri, LDS,Kaiser Permanente, University of Missouri, LDS,Regenstrief Institute, ColumbiaRegenstrief Institute, Columbia’’s Presbyterian,s Presbyterian,Duke, and Vanderbilt, as well as BU, Tufts,Duke, and Vanderbilt, as well as BU, Tufts,MGH, Brigham and WomenMGH, Brigham and Women’’s and BIDMCs and BIDMChospitals, have proved to be highly useful inhospitals, have proved to be highly useful inthe practice of medicine.the practice of medicine.

Cybermedicine for the PatientCybermedicine for the PatientCybermedicine for the Patient

Early experienceEarly experienceEarly experience

Fig. 6.1 The LINC (Laboratory Instrument Computer) in use in a medical interview in 1968. (Reproduced from Slack WV, Van Cura LJ. “Patient reaction to computer-based medical interviewing.” Computers and Biomedical Research 1 (1968): 527-531. Courtesy Elsevier, Inc., http://www.sciencedirect.com. Used with permission.)

Fig. 6.1Fig. 6.1 The LINC (Laboratory Instrument Computer) in use in a medicalThe LINC (Laboratory Instrument Computer) in use in a medical interview in 1968. interview in 1968. (Reproduced from Slack WV, Van Cura LJ. (Reproduced from Slack WV, Van Cura LJ. ““Patient reaction to computerPatient reaction to computer--based medical interviewing.based medical interviewing.”” Computers and Computers and Biomedical Research Biomedical Research 1 (1968): 5271 (1968): 527--531. Courtesy Elsevier, Inc., http://531. Courtesy Elsevier, Inc., http://www.sciencedirect.comwww.sciencedirect.com. Used with permission.). Used with permission.)


Long-Standing Problems:LongLong--Standing Problems:Standing Problems:


Long-Standing Problems:

1. Time limitations beyond the doctor’s control>incomplete histories>insufficient counseling

LongLong--Standing Problems:Standing Problems:

1.1. Time limitations beyond the doctorTime limitations beyond the doctor’’s controls control>incomplete histories>incomplete histories>insufficient counseling>insufficient counseling


Long-Standing Problems:

1. Time limitations beyond the doctor’s control>incomplete histories>insufficient counseling

2. Handwritten record>laborious>incomplete and illegible

LongLong--Standing Problems:Standing Problems:

1.1. Time limitations beyond the doctorTime limitations beyond the doctor’’s controls control>incomplete histories>incomplete histories>insufficient counseling>insufficient counseling

2.2. Handwritten recordHandwritten record>laborious>laborious>incomplete and illegible>incomplete and illegible


More Recent Problems:More Recent Problems:More Recent Problems:


More Recent Problems:

3. Doctors are pressured by increasingly empowered patients who with good reason want and expect more personal attention

More Recent Problems:More Recent Problems:

3.3. Doctors are pressured by increasingly Doctors are pressured by increasingly empowered patients who empowered patients who with good with good reasonreason want and expect more personal want and expect more personal attention attention


More Recent Problems:

3. Doctors are pressured by increasingly empowered patients who with good reasonwant and expect more personal attention

4. Doctors are pressured by financially-pressured administrators, who with questionable reason schedule more and more patients in shorter and shorter intervals

More Recent Problems:More Recent Problems:

3.3. Doctors are pressured by increasingly Doctors are pressured by increasingly empowered patients who empowered patients who with good reasonwith good reasonwant and expect more personal attention want and expect more personal attention

4.4. Doctors are pressured by financiallyDoctors are pressured by financially--pressured administrators, who pressured administrators, who with with questionable reasonquestionable reason schedule more and schedule more and more patients in shorter and shorter intervalsmore patients in shorter and shorter intervals


Patient PowerOpportunity Afforded by the ComputerFirst PatientFirst StudyShared Record

Patient PowerPatient PowerOpportunity Afforded by the ComputerOpportunity Afforded by the ComputerFirst PatientFirst PatientFirst StudyFirst StudyShared RecordShared Record

Problems

Problems Detected by

Both Physician & Computer

Problems Detected by Physician

Only

Problems Detected by Computer

Only

Urticaria 0 0 12

Allergic rhinitis 2 0 7

Asthma 4 0 2

Drug allergy 7 0 1

Slack, W.V. et al, New England Journal of Medicine, 1966

Problems

Problems Detected by

Both Physician & Computer

Problems Detected by Physician

Only

Problems Detected by Computer

Only

Urticaria 0 0 12

Allergic rhinitis 2 0 7

Asthma 4 0 2

Drug allergy 7 0 1

Slack, W.V. et al, New England Journal of Medicine, 1966

Comparison Between Physicians and Computer when Interviewing Patients About Problems with Allergies

Comparison Between Physicians and Computer when Interviewing Patients About Problems with Allergies


Early results led to further study and efforts to enhance rapport and yield further control.

Early results led to further study and Early results led to further study and efforts to enhance rapport and yield efforts to enhance rapport and yield further control. further control.

Yielding ControlYielding ControlYielding Control

requesting permission to proceedrequesting permission to proceedrequesting permission to proceed


requesting permission to proceedproviding sufficient informationrequesting permission to proceedrequesting permission to proceedproviding sufficient informationproviding sufficient information


requesting permission to proceedproviding sufficient informationrespecting priorities

requesting permission to proceedrequesting permission to proceedproviding sufficient informationproviding sufficient informationrespecting prioritiesrespecting priorities


requesting permission to proceedproviding sufficient informationrespecting prioritiesoffering alternatives

requesting permission to proceedrequesting permission to proceedproviding sufficient informationproviding sufficient informationrespecting prioritiesrespecting prioritiesoffering alternativesoffering alternatives


requesting permission to proceedproviding sufficient informationrespecting prioritiesoffering alternativesrespecting the right to decide

requesting permission to proceedrequesting permission to proceedproviding sufficient informationproviding sufficient informationrespecting prioritiesrespecting prioritiesoffering alternativesoffering alternativesrespecting the right to deciderespecting the right to decide


requesting permission to proceedproviding sufficient informationrespecting prioritiesoffering alternativesrespecting the right to deciderespecting the right not to decide

requesting permission to proceedrequesting permission to proceedproviding sufficient informationproviding sufficient informationrespecting prioritiesrespecting prioritiesoffering alternativesoffering alternativesrespecting the right to deciderespecting the right to deciderespecting the right not to deciderespecting the right not to decide


requesting permission to proceedproviding sufficient informationrespecting prioritiesoffering alternativesrespecting the right to deciderespecting the right not to decidehelping with uncertainty

requesting permission to proceedrequesting permission to proceedproviding sufficient informationproviding sufficient informationrespecting prioritiesrespecting prioritiesoffering alternativesoffering alternativesrespecting the right to deciderespecting the right to deciderespecting the right not to deciderespecting the right not to decidehelping with uncertaintyhelping with uncertainty


requesting permission to proceedproviding sufficient informationrespecting prioritiesoffering alternativesrespecting the right to deciderespecting the right not to decidehelping with uncertaintyrespecting reluctance to respond

requesting permission to proceedrequesting permission to proceedproviding sufficient informationproviding sufficient informationrespecting prioritiesrespecting prioritiesoffering alternativesoffering alternativesrespecting the right to deciderespecting the right to deciderespecting the right not to deciderespecting the right not to decidehelping with uncertaintyhelping with uncertaintyrespecting reluctance to respondrespecting reluctance to respond


Patient-Computer DialoguePatientPatient--Computer DialogueComputer Dialogue

A Computer-Based Health Care Interview for Hospital PersonnelA ComputerA Computer--Based Health Care Based Health Care Interview for Hospital PersonnelInterview for Hospital Personnel

The Seven Health-Related Sections of the Interview

The Seven HealthThe Seven Health--Related Related Sections of the InterviewSections of the Interview

General medical historyGeneral medical historyGeneral medical history



General medical historyNutrition historyGeneral medical historyGeneral medical historyNutrition historyNutrition history



General medical historyNutrition historyExercise patterns

General medical historyGeneral medical historyNutrition historyNutrition historyExercise patternsExercise patterns



General medical historyNutrition historyExercise patternsHabits

General medical historyGeneral medical historyNutrition historyNutrition historyExercise patternsExercise patternsHabitsHabits



General medical historyNutrition historyExercise patternsHabitsSafety

General medical historyGeneral medical historyNutrition historyNutrition historyExercise patternsExercise patternsHabitsHabitsSafetySafety



General medical historyNutrition historyExercise patternsHabitsSafetyEnvironment

General medical historyGeneral medical historyNutrition historyNutrition historyExercise patternsExercise patternsHabitsHabitsSafetySafetyEnvironmentEnvironment



General medical historyNutrition historyExercise patternsHabitsSafetyEnvironmentStress

General medical historyGeneral medical historyNutrition historyNutrition historyExercise patternsExercise patternsHabitsHabitsSafetySafetyEnvironmentEnvironmentStressStress

StressStressStress

In the PAST MONTH have you felt sad, discouraged or hopeless?

1. Yes2. No3. Maybe4. Don’t understand5. Skip it

Answer: 1

In the PAST MONTH have you felt sad, In the PAST MONTH have you felt sad, discouraged or hopeless?discouraged or hopeless?

1.1. YesYes2. 2. NoNo3. 3. MaybeMaybe4. 4. DonDon’’t understandt understand5.5. Skip itSkip it

Answer: Answer: 11

StressStressStress

In the PAST MONTH has life sometimes seemed as if it’s not worth living?


Answer: 1

In the PAST MONTH has life sometimes In the PAST MONTH has life sometimes seemed as if itseemed as if it’’s not worth living?s not worth living?

11. Yes. Yes2. 2. NoNo3. 3. MaybeMaybe4. 4. DonDon’’t understandt understand5. 5. Skip itSkip it

Answer: Answer: 11

StressStressStress

When life seems like it’s not worth living, it’s often helpful to speak to someone about these feelings.

<ENTER>

When life seems like itWhen life seems like it’’s not worth living, s not worth living, itit’’s often helpful to speak to someone s often helpful to speak to someone about these feelings.about these feelings.

<ENTER><ENTER>

StressStressStress

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

<ENTER>

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

<ENTER><ENTER>

StressStressStress

Help is available any time day or night through the:Employee Assistance Program - (617) 123-1234

Samaritans - (617) 222-3131

Or you can always contact the Emergency Room (Ext. 3337)

Please be assured that whatever you say will be kept confidential

Help is available any time day or night through the:Help is available any time day or night through the:Employee Assistance Program Employee Assistance Program -- (617) 123(617) 123--12341234

Samaritans Samaritans -- (617) 222(617) 222--31313131

Or you can always contact the Emergency Or you can always contact the Emergency Room (Ext. 3337)Room (Ext. 3337)

Please be assured that whatever you say will be kept Please be assured that whatever you say will be kept confidentialconfidential

StressStressStress

Would you like to discuss this when you visit with your employee nurse?


Answer: 1

Would you like to discuss this when you visit Would you like to discuss this when you visit with your employee nurse?with your employee nurse?

1.1. YesYes2. No2. No3. Maybe3. Maybe4. 4. DonDon’’t understandt understand5. 5. Skip itSkip it

Answer: Answer: 11

StressStressStress

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. Yes2. No

Answer: 2

You will be receiving a printed summary of this You will be receiving a printed summary of this interview at that visit.interview at that visit.

Would it be ok to indicate on your summary that you Would it be ok to indicate on your summary that you would like to discuss this issue?would like to discuss this issue?

1. 1. YesYes2. 2. NoNo

Answer:Answer: 22

StressStressStress

That’s fine, but please feel free to talk about it at your visit.

<ENTER>

ThatThat’’s fine, but please feel free to talk s fine, but please feel free to talk about it at your visit.about it at your visit.

<ENTER><ENTER>

Sex DistributionSex Sex DistributionDistribution

Males 530Females 1407

Total 1937

MalesMales 530530FemalesFemales 14071407

TotalTotal 19371937

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

Yes 811 (42%)No 890 (46%)Maybe 190 (10%)Don’t understand 12 (1%)Skip it 34 (2%)

YesYes 811811 (42%)(42%)NoNo 890890 (46%)(46%)MaybeMaybe 190190 (10%)(10%)DonDon’’t understandt understand 1212 (1%)(1%)Skip itSkip it 3434 (2%)(2%)

In the past month has life sometimes seemed like it’s not worth living?In the past month has life sometimes In the past month has life sometimes seemed like itseemed like it’’s not worth living?s not worth living?

Yes 106 (6%)No 812 (42%)Maybe 57 (3%)Don’t understand 3 (0%)Skip it 33 (2%)

YesYes 106106 (6%)(6%)NoNo 812812 (42%)(42%)MaybeMaybe 5757 (3%)(3%)DonDon’’t understandt understand 33 (0%)(0%)Skip itSkip it 3333 (2%)(2%)

Health-Related Program RequestsHealthHealth--Related Program RequestsRelated Program Requests

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

Total 2952

Fitness CenterFitness Center 13851385Stress ReductionStress Reduction 724724Time ManagementTime Management 457457LowLow--Back ProtectionBack Protection 260260Smoking CessationSmoking Cessation 126126

TotalTotal 29522952


Concerns about the computer as anegative, depersonalizing influencewould prove unfounded.

Concerns about the computer as aConcerns about the computer as anegative, depersonalizing influencenegative, depersonalizing influencewould prove unfounded.would prove unfounded.

PreferenceComputer vs. Doctor or Nurse

PreferencePreferenceComputer vs. Doctor or NurseComputer vs. Doctor or Nurse

12%3%39%

46%

Doctor or nurse ComputerNo preference Skip it

12%3%39%

46%

Doctor or nurse ComputerNo preference Skip it

16%6% 78%16%6% 78%

50%

42%8%50%

42%8%

Did the computer sometimes ask more than you wanted to tell?

Did the computer sometimes ask more than you wanted to tell?

Did you sometimes want totell the computer more than it asked?

Did you sometimes want totell the computer more than it asked?

YesYesYes NoNoNo UncertainUncertainUncertain

Revelation in the Absence of aFace-to-Face Encounter

Revelation in the Absence of aRevelation in the Absence of aFaceFace--toto--Face EncounterFace Encounter

Improved Alcohol ScreeningImproved Alcohol ScreeningImproved Alcohol Screening

Computer interview, but not doctor’s note 14

Doctor’s note, but not computer interview 0

Computer interview and doctor’s note 80

Computer interview, but ? doctor’s note 6

Computer interviewComputer interview, , but not doctorbut not doctor’’s note 14s note 14

DoctorDoctor’’s note, but not computer interview s note, but not computer interview 00

Computer interview and doctorComputer interview and doctor’’s note s note 8080

Computer interview, but ? doctorComputer interview, but ? doctor’’s notes note 66

Interview selfInterview self--reported vs. clinicianreported vs. clinician--documenteddocumentedalcohol use were compared for 100 initial visitsalcohol use were compared for 100 initial visits

Discrepant Case #1Discrepant Case #1Discrepant Case #1

MD’s note“uses alcohol socially”

Computer’s note“frequency 2-3/week, 3-4/day, 6+ drinks

monthly, blackouts monthly”

MDMD’’s notes note““uses alcohol uses alcohol sociallysocially””

ComputerComputer’’s notes note““frequency 2frequency 2--3/week, 33/week, 3--4/day, 6+ drinks 4/day, 6+ drinks

monthly, monthly, blackouts monthlyblackouts monthly””

Discrepant Case #2Discrepant Case #2Discrepant Case #2

MD’s note“occasional ETOH”

Computer’s note“had drinking problem in the past,

abstinent now”

MDMD’’s notes note““occasional ETOHoccasional ETOH””

ComputerComputer’’s notes note““had drinking problem in the pasthad drinking problem in the past, ,

abstinent nowabstinent now””

Revelation in the Absence of aFace-to-Face Encounter

Revelation in the Absence of aRevelation in the Absence of aFaceFace--toto--Face EncounterFace Encounter

Computer-based interview of potential blood donors elicited more HIV-related factors in the health histories than the standard questionnaire and interpersonal interviewing methods currently in use at the Red Cross.

ComputerComputer--based interview of potential blood based interview of potential blood donors elicited more HIVdonors elicited more HIV--related factors in related factors in the health histories than the standard the health histories than the standard questionnaire and interpersonal interviewing questionnaire and interpersonal interviewing methods currently in use at the Red Cross. methods currently in use at the Red Cross.

Computer-Based Screeningfor HIV Risk

ComputerComputer--BasedBased ScreeningScreeningfor HIV Riskfor HIV Risk

0

10

20

30

40

50

60

70% of Subjects

More Honest withComputer

Equally Honest More Honest withHuman Interviewer

0

10

20

30

40

50

60

70% of Subjects

More Honest withComputer

Equally Honest More Honest withHuman Interviewer

Locke SE, et al. JAMA, 1992 Locke SE, et al. JAMA, 1992


Printed summaries developed with thepatient as well as the doctor in mind.Printed summaries developed with thePrinted summaries developed with thepatientpatient as well as the doctor in mind.as well as the doctor in mind.


Dialogue between patient and doctorthe mainstay of clinical medicine,but with problems

Patient-computer dialogue onepossible solution

Dialogue between patient and doctorDialogue between patient and doctorthe mainstay of clinical medicine,the mainstay of clinical medicine,but with problemsbut with problems

PatientPatient--computer dialogue onecomputer dialogue onepossible solutionpossible solution


The Internet as a mediator ofpatient-computer dialogueThe Internet as a mediator ofThe Internet as a mediator ofpatientpatient--computer dialoguecomputer dialogue


The patient as a health-care resourceThe The patientpatient as a healthas a health--care resourcecare resource


The Computer as a Patient’s AssistantThe Computer as a PatientThe Computer as a Patient’’s Assistants Assistant


Urinary Tract InfectionUrinary Tract InfectionUrinary Tract Infection


Teaching program for use of the computerTeaching program for use of the computerTeaching program for use of the computer


Teaching program for use of the computerGeneral medical history, conditions for referral, and referral if indicated

Teaching program for use of the computerTeaching program for use of the computerGeneral medical history, conditions for General medical history, conditions for referral, and referral if indicatedreferral, and referral if indicated


Teaching program for use of the computerGeneral medical history, conditions for referral, and referral if indicatedHistory referable to urinary tract infection

Teaching program for use of the computerTeaching program for use of the computerGeneral medical history, conditions for General medical history, conditions for referral, and referral if indicatedreferral, and referral if indicatedHistory referable to urinary tract infectionHistory referable to urinary tract infection


Teaching program for use of the computerGeneral medical history, conditions for referral, and referral if indicatedHistory referable to urinary tract infectionUrine culture

Teaching program for use of the computerTeaching program for use of the computerGeneral medical history, conditions for General medical history, conditions for referral, and referral if indicatedreferral, and referral if indicatedHistory referable to urinary tract infectionHistory referable to urinary tract infectionUrine cultureUrine culture


Teaching program for use of the computerGeneral medical history, conditions for referral, and referral if indicatedHistory referable to urinary tract infectionUrine cultureDiscussion of therapy

Teaching program for use of the computerTeaching program for use of the computerGeneral medical history, conditions for General medical history, conditions for referral, and referral if indicatedreferral, and referral if indicatedHistory referable to urinary tract infectionHistory referable to urinary tract infectionUrine cultureUrine cultureDiscussion of therapyDiscussion of therapy


Teaching program for use of the computerGeneral medical history, conditions for referral, and referral if indicatedHistory referable to urinary tract infectionUrine cultureDiscussion of therapyPatient’s Choice about treatment

Teaching program for use of the computerTeaching program for use of the computerGeneral medical history, conditions for General medical history, conditions for referral, and referral if indicatedreferral, and referral if indicatedHistory referable to urinary tract infectionHistory referable to urinary tract infectionUrine cultureUrine cultureDiscussion of therapyDiscussion of therapyPatientPatient’’s Choice about treatments Choice about treatment


Teaching program for use of the computerGeneral medical history, conditions for referral, and referral if indicatedHistory referable to urinary tract infectionUrine cultureDiscussion of therapyPatient’s Choice about treatmentTherapy

Teaching program for use of the computerTeaching program for use of the computerGeneral medical history, conditions for General medical history, conditions for referral, and referral if indicatedreferral, and referral if indicatedHistory referable to urinary tract infectionHistory referable to urinary tract infectionUrine cultureUrine cultureDiscussion of therapyDiscussion of therapyPatientPatient’’s Choice about treatments Choice about treatmentTherapyTherapy


Teaching program for use of the computerGeneral medical history, conditions for referral, and referral if indicatedHistory referable to urinary tract infectionUrine cultureDiscussion of therapyPatient’s Choice about treatmentTherapyReturn Visit

Teaching program for use of the computerTeaching program for use of the computerGeneral medical history, conditions for General medical history, conditions for referral, and referral if indicatedreferral, and referral if indicatedHistory referable to urinary tract infectionHistory referable to urinary tract infectionUrine cultureUrine cultureDiscussion of therapyDiscussion of therapyPatientPatient’’s Choice about treatments Choice about treatmentTherapyTherapyReturn VisitReturn Visit


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

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

Patient-Computer DialoguePatientPatient--ComputerComputer DialogueDialogue

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

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

Patient-Computer DialoguePatientPatient--ComputerComputer DialogueDialogue

Are you bothered by pain or burning when you urinate?

1.Yes2. No3. Maybe ( don’t know)4. Don’t understand5. Skip it

Are you bothered by pain or burning Are you bothered by pain or burning when you urinate?when you urinate?

1.Yes1.Yes2. No2. No3. Maybe ( don3. Maybe ( don’’t know)t know)4. Don4. Don’’t understandt understand5. Skip it5. Skip it


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

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

Which is most important to you: 1Which is most important to you: 1


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: 1and which is least important : 5

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

Which is most important to you: 1Which is most important to you: 1and which is least important : 5and which is least important : 5


You indicated that knowing how well sulfa works is perhaps most important to you...

Let’s consider this first.

You indicated that knowing how well You indicated that knowing how well sulfa works is perhaps most sulfa works is perhaps most important to you...important to you...

LetLet’’s consider this firsts consider this first..


Before deciding about sulfa, would you like to go over anything again?

1. Yes2. No3. Maybe ( don’t know)4. Don’t understand5. Skip it

Before deciding about sulfa, would you Before deciding about sulfa, would you like to go over anything again?like to go over anything again?

1. Yes1. Yes2. No2. No3. Maybe ( don3. Maybe ( don’’t know)t know)4. Don4. Don’’t understandt understand5. Skip it5. Skip it


Very well then...would you like to 1. Take sulfa2. Take nothing3. Consider another medicine4. Uncertain (can’t decide)

Very well then...would you like to Very well then...would you like to 1. Take sulfa1. Take sulfa2. Take nothing2. Take nothing3. Consider another medicine3. Consider another medicine4. Uncertain (can4. Uncertain (can’’t decide)t decide)


It seems that you took some extra time with your answer. Does this mean that you’ve been:

1. Thinking it over and feel you’ve made the right choice?

2. Trying to get things clear butaren’t sure about your choice?

It seems that you took some extra time It seems that you took some extra time with your answer. Does this mean that with your answer. Does this mean that youyou’’ve been:ve been:

1. Thinking it over and feel you1. Thinking it over and feel you’’ve ve made the right choice?made the right choice?

2. Trying to get things clear but2. Trying to get things clear butarenaren’’t sure about your choice?t sure about your choice?


We hope it’s OK then, to ask again what is your decision?

1. Uncertain (can’t decide)2. Consider another medicine 3. Take nothing4. Take sulfa

We hope itWe hope it’’s OK then, to ask again what is s OK then, to ask again what is your decision?your decision?

1. Uncertain (can1. Uncertain (can’’t decide)t decide)2. Consider another medicine 2. Consider another medicine 3. Take nothing3. Take nothing4. Take sulfa4. Take sulfa

Results (46 Patients)Results Results (46 Patients)(46 Patients)

10 referred by the program for further evaluation

35 decided to take sulfisoxazole

1 decided to wait for culture, which was negative

10 referred by the program for further evaluation10 referred by the program for further evaluation

35 decided to take sulfisoxazole35 decided to take sulfisoxazole

1 decided to wait for culture, which was negative1 decided to wait for culture, which was negative

Patients’ Reaction to the ComputerPatientsPatients’’ Reaction to the ComputerReaction to the Computer

How has it been to decide for yourself about taking sulfa?

A good thing 30Better left up to someone else 1No preference either way 3Not sure 2

How has it been to decide for yourself How has it been to decide for yourself about taking sulfa?about taking sulfa?

A good thingA good thing 3030Better left up to someone elseBetter left up to someone else 11No preference either wayNo preference either way 33Not sureNot sure 22

Patients’ Reaction to the ComputerPatientsPatients’’ Reaction to the ComputerReaction to the Computer

Was the computer considerate?

Yes 34No 0Maybe 0Don’t understand 0Skip it 2

Was the computer considerate?Was the computer considerate?

YesYes 3434NoNo 00MaybeMaybe 00DonDon’’t understandt understand 00Skip itSkip it 22


More research is needed.More research is needed.More research is needed.

Image removed due to copyright restrictions.Image removed due to copyright restrictions.

Cartoon about computers replacing psychotherapists.Cartoon about computers replacing psychotherapists.


Patient Site (a secure Web Site)Patient Site (a secure Web Site)Patient Site (a secure Web Site)


Patient Site (a secure Web Site)

view results of diagnostic studies

Patient Site (a secure Web Site)Patient Site (a secure Web Site)

view results of diagnostic studiesview results of diagnostic studies



view results of diagnostic studiesview medications


view results of diagnostic studiesview results of diagnostic studiesview medicationsview medications



view results of diagnostic studiesview medicationsrequest prescriptions


view results of diagnostic studiesview results of diagnostic studiesview medicationsview medicationsrequest prescriptionsrequest prescriptions



view results of diagnostic studiesview medicationsrequest prescriptionsrequest appointments and referrals


view results of diagnostic studiesview results of diagnostic studiesview medicationsview medicationsrequest prescriptionsrequest prescriptionsrequest appointments and referralsrequest appointments and referrals



view results of diagnostic studiesview medicationsrequest prescriptionsrequest appointments and referralscommunicate with doctors & staff


view results of diagnostic studiesview results of diagnostic studiesview medicationsview medicationsrequest prescriptionsrequest prescriptionsrequest appointments and referralsrequest appointments and referralscommunicate with doctors & staffcommunicate with doctors & staff

Cybermedicine for bothPatient and Clinician

Cybermedicine for bothCybermedicine for bothPatient and ClinicianPatient and Clinician

The ClinHaven, and a hope for the futureThe ClinHaven, and a hope for the futureThe ClinHaven, and a hope for the future

Image removed due to copyright restrictions.Image removed due to copyright restrictions.

Cartoon about stereotypically illegible doctor handwriting.Cartoon about stereotypically illegible doctor handwriting.

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