biomedical informatics year in review 2008 notable publications and events in informatics during...

Biomedical Informatics Biomedical Informatics Year in ReviewYear in Review

20082008Notable publications and events in Informatics Notable publications and events in Informatics

during 2008during 2008

Robert N. Enberg, MD, MMMRobert N. Enberg, MD, MMM

Clinical Systems Research and IntegrationClinical Systems Research and Integration

January 26, 2009January 26, 2009

This literature review is based on a presentation This literature review is based on a presentation by Daniel R. Masys, MD, Professor and Chair, by Daniel R. Masys, MD, Professor and Chair, Department of Biomedical Informatics, Vanderbilt Department of Biomedical Informatics, Vanderbilt University School of Medicine at the 2007 annual University School of Medicine at the 2007 annual meeting of the American Medical Informatics meeting of the American Medical Informatics Association.Association.

Source of Content for Source of Content for SessionSession

• Literature review of randomized Literature review of randomized controlled trials indexed by MeSH term controlled trials indexed by MeSH term “Medical Informatics”, “Telemedicine” & “Medical Informatics”, “Telemedicine” & descendents or main MeSH term descendents or main MeSH term “Bioinformatics”, and further qualified “Bioinformatics”, and further qualified by involvement of >100 providers or by involvement of >100 providers or patients (n=31)patients (n=31)

• Poll of American College of Medical Poll of American College of Medical Informatics fellows listInformatics fellows list

New Literature Highlights: New Literature Highlights: Clinical InformaticsClinical Informatics

• Clinical Decision SupportClinical Decision Support• Personal Health RecordsPersonal Health Records• TelemedicineTelemedicine• The Practice of InformaticsThe Practice of Informatics

Consider the following:Consider the following:

• Are the improvements evolutionary Are the improvements evolutionary or transformational?or transformational?

• Could we have done the study Could we have done the study here?here?

• Should we be doing these kinds of Should we be doing these kinds of studies?studies?

• If so, what research infrastructure If so, what research infrastructure would be necessary?would be necessary?

Clinical Decision SupportClinical Decision Support

-for providers-for providers

-for patients-for patients

Clinical Decision Support for Clinical Decision Support for ProvidersProviders

• Reference 1Reference 1– Stevens J et al. Pediatrics. 2008 Jun;121(6):1099-105. [Childrens Stevens J et al. Pediatrics. 2008 Jun;121(6):1099-105. [Childrens

Hospital, Columbus, OH]Hospital, Columbus, OH]

• TitleTitle– Trial of computerized screening for adolescent Trial of computerized screening for adolescent

behavioral concerns.behavioral concerns.• AimAim

– to determine whether computerized screening with to determine whether computerized screening with real-time printing of results for pediatricians real-time printing of results for pediatricians increased the identification of injury risk, depressive increased the identification of injury risk, depressive symptoms, and substance use among adolescents.symptoms, and substance use among adolescents.

• MethodsMethods– 878 primary care pts 11-20 yrs old from low income 878 primary care pts 11-20 yrs old from low income

populationspopulations

• Methods, cont’dMethods, cont’d– Clinics randomly assigned to have pediatricians Clinics randomly assigned to have pediatricians

receive screening results either just before face-receive screening results either just before face-to-face encounters with patients (immediate-to-face encounters with patients (immediate-results condition) or 2 to 3 business days later results condition) or 2 to 3 business days later (delayed-results condition)(delayed-results condition)

– Measures: numbers of conditions identified and Measures: numbers of conditions identified and recognition rate by clinical providers.recognition rate by clinical providers.

• ResultsResults– 59% of respondents had 1 or more behavioral 59% of respondents had 1 or more behavioral

issuesissues– Of those screen positive, 68% were identified and Of those screen positive, 68% were identified and

documented by clinicians vs. 52% in delayed documented by clinicians vs. 52% in delayed results groupresults group


• ImportanceImportance– Adds to an extensive literature that patient Adds to an extensive literature that patient

provided information via a variety of care provided information via a variety of care setting input methods (portals, waiting setting input methods (portals, waiting room kiosks and workstations, tablet PCs) room kiosks and workstations, tablet PCs) can influence identification and care can influence identification and care planning for health conditionsplanning for health conditions



• Reference 2Reference 2– Poller et al. J Thromb Haemost. 2008 Jun;6(6):935-43. [Univ. Poller et al. J Thromb Haemost. 2008 Jun;6(6):935-43. [Univ.

Manchester, UK]Manchester, UK]

• TitleTitle– An international multicenter randomized study of computer-An international multicenter randomized study of computer-

assisted oral anticoagulant dosage vs. medical staff dosage.assisted oral anticoagulant dosage vs. medical staff dosage.• AimAim

– To compare the safety and effectiveness of computer-To compare the safety and effectiveness of computer-assisted dosage with dosage by experienced medical staff assisted dosage with dosage by experienced medical staff at the same centers.at the same centers.

• MethodsMethods– A randomized study of dosage of two commercial A randomized study of dosage of two commercial

computer-assisted dosage programs (PARMA 5 and DAWN computer-assisted dosage programs (PARMA 5 and DAWN AC) vs. manual dosage at 32 centers in 13 countries. AC) vs. manual dosage at 32 centers in 13 countries.


• Methods, cont’dMethods, cont’d– Safety and effectiveness of computer-assisted Safety and effectiveness of computer-assisted

dosage were compared with those of medical staff dosage were compared with those of medical staff dosage.dosage.

• ResultsResults– 13,219 patients participated, 6503 patients being 13,219 patients participated, 6503 patients being

randomized to medical staff and 6716 to computer-randomized to medical staff and 6716 to computer-assisted dosage. assisted dosage.

– International Normalized Ratio (INR) tests numbered International Normalized Ratio (INR) tests numbered 193,890 with manual dosage and 193,424 with 193,890 with manual dosage and 193,424 with computer-assisted dosage.computer-assisted dosage.

– In the 3209 patients with deep vein thrombosis/ In the 3209 patients with deep vein thrombosis/ pulmonary embolism, 37 fewer clinical events (24%, pulmonary embolism, 37 fewer clinical events (24%, P = 0.001) for computer assisted dosage.P = 0.001) for computer assisted dosage.


• Results, cont’dResults, cont’d– Time in target INR range improved with Time in target INR range improved with

computer assisted dosage (P<.0001)computer assisted dosage (P<.0001)• ImportanceImportance

– Adds to an extensive literature on Adds to an extensive literature on anticoagulant dosage clinical decision anticoagulant dosage clinical decision support that has consistently shown support that has consistently shown outcomes improvement vs. unaided outcomes improvement vs. unaided clinician judgment. clinician judgment.

– First international multicenter study (32 First international multicenter study (32 sites) to show that effects are robust sites) to show that effects are robust across a large number of care settings across a large number of care settings worldwide worldwide

Clinical Decision Support for Clinical Decision Support for ProvidersProviders• Reference 3Reference 3

– Weber V, White A, McIlvried R. J Gen Intern Med. 2008 Apr;23(4):399-404. Weber V, White A, McIlvried R. J Gen Intern Med. 2008 Apr;23(4):399-404. [Geisinger Health Sys, Danville PA][Geisinger Health Sys, Danville PA]

• TitleTitle– An electronic medical record (EMR)-based intervention to An electronic medical record (EMR)-based intervention to

reduce polypharmacy and falls in an ambulatory rural elderly reduce polypharmacy and falls in an ambulatory rural elderly population.population.

• AimAim– To evaluate an EMR-based intervention to reduce overall To evaluate an EMR-based intervention to reduce overall

medication use, psychoactive medication use, and occurrence medication use, psychoactive medication use, and occurrence of falls in an ambulatory elderly population at risk for falls.of falls in an ambulatory elderly population at risk for falls.

• MethodsMethods– Standardized medication review conducted and Standardized medication review conducted and

recommendations made to the primary physician via the recommendations made to the primary physician via the EMR. Randomized by clinic to intervention vs. normal careEMR. Randomized by clinic to intervention vs. normal care

• Methods, cont’dMethods, cont’d– Patients contacted to obtain self reports of falls at 3-Patients contacted to obtain self reports of falls at 3-

month intervals over the 15-month period of study. month intervals over the 15-month period of study. – Fall-related diagnoses and medication data were Fall-related diagnoses and medication data were

collected through the EMR.collected through the EMR.• ResultsResults

– 620 Pts over age 70 enrolled.620 Pts over age 70 enrolled.– Intervention did not reduce the total number of Intervention did not reduce the total number of

medications, but reduced prescribing of psychoactive medications, but reduced prescribing of psychoactive meds (P < .01)meds (P < .01)

– Intervention group had 0.38 risk of falls vs. controls Intervention group had 0.38 risk of falls vs. controls as documented by EMR (P < .01) but no difference as documented by EMR (P < .01) but no difference when self report data added. when self report data added.


• ConclusionConclusion– EMR to assess medication use in the elderly EMR to assess medication use in the elderly

may reduce the use of psychoactive may reduce the use of psychoactive medications and falls in a community-medications and falls in a community-dwelling elderly population.dwelling elderly population.

• ImpactImpact– Looking only inside the EMR may miss real Looking only inside the EMR may miss real

world health events. Best to gather world health events. Best to gather independent observations if possible in independent observations if possible in interventional studies. interventional studies.



– van Wyk et al. Circulation. 2008 Jan 22;117(3):371-8. [Erasmus van Wyk et al. Circulation. 2008 Jan 22;117(3):371-8. [Erasmus Univ, Rotterdam, Netherlands].Univ, Rotterdam, Netherlands].

• TitleTitle– Electronic alerts versus on-demand decision support to improve Electronic alerts versus on-demand decision support to improve

dyslipidemia treatment: a cluster randomized controlled trial.dyslipidemia treatment: a cluster randomized controlled trial.• AimAim

– To study the effect of both alerting and on-demand decision To study the effect of both alerting and on-demand decision support with respect to screening and treatment of dyslipidemia support with respect to screening and treatment of dyslipidemia based on guidelines of the Dutch College of General based on guidelines of the Dutch College of General Practitioners. Practitioners.

• MethodsMethods– Cluster randomized trial 38 Dutch general practices (77 Cluster randomized trial 38 Dutch general practices (77

physicians) who used the ELIAS electronic health record, and physicians) who used the ELIAS electronic health record, and 87,886 of their patients87,886 of their patients

Clinical Decision Support for Clinical Decision Support for ProvidersProviders• Methods, cont’dMethods, cont’d

– Each practice assigned to receive alerts, on-demand Each practice assigned to receive alerts, on-demand support, or no intervention. support, or no intervention.

– Outcome: percentage of patients screened and Outcome: percentage of patients screened and treated after 12 months of follow-up.treated after 12 months of follow-up.

• ResultsResults– In alerting group, 65% of Pts requiring screening In alerting group, 65% of Pts requiring screening

were screened vs. 35% of Pts in the on-demand were screened vs. 35% of Pts in the on-demand group and 25% of Pts in control group. group and 25% of Pts in control group.

– In alerting group, 66% of patients requiring Rx were In alerting group, 66% of patients requiring Rx were treated vs. 40% of Pts in on-demand group and 36% treated vs. 40% of Pts in on-demand group and 36% of Pts in the control group. of Pts in the control group.


• ConclusionsConclusions– Alerting version of the clinical decision support Alerting version of the clinical decision support

systems significantly improved screening and systems significantly improved screening and treatment performance for dyslipidemia by general treatment performance for dyslipidemia by general practitioners.practitioners.

• ImpactImpact– Magnitude of improvements in guideline adherence Magnitude of improvements in guideline adherence

historically associated with inpatient settings can historically associated with inpatient settings can be observed in primary care outpatient settings for be observed in primary care outpatient settings for common disorders, using a practice-based EMR (in common disorders, using a practice-based EMR (in the Netherlands). the Netherlands).

– More evidence of Northern Europe leading in More evidence of Northern Europe leading in ambulatory practice innovations vs. USambulatory practice innovations vs. US


– Mulvaney SA et al. J Am Med Inform Assoc. 2008 Mar-Apr;15(2):203-11. [Vanderbilt, Mulvaney SA et al. J Am Med Inform Assoc. 2008 Mar-Apr;15(2):203-11. [Vanderbilt, Nashville, TN]Nashville, TN]

• TitleTitle– A randomized effectiveness trial of a clinical informatics consult A randomized effectiveness trial of a clinical informatics consult

service: impact on evidence-based decision-making and knowledge service: impact on evidence-based decision-making and knowledge implementation. implementation.

• AimAim– To determine the effectiveness of providing synthesized research To determine the effectiveness of providing synthesized research

evidence to inform patient care practices via an evidence based evidence to inform patient care practices via an evidence based informatics program, the Clinical Informatics Consult Service (CICS). informatics program, the Clinical Informatics Consult Service (CICS).

• MethodsMethods– Consults randomly assigned to CICS Provided, where clinicians Consults randomly assigned to CICS Provided, where clinicians

received synthesized information from literature addressing the received synthesized information from literature addressing the consult question or No CICS Provided, in which no information was consult question or No CICS Provided, in which no information was provided.provided.

Clinical Decision Support for Clinical Decision Support for ProvidersProviders• Methods, cont’dMethods, cont’d

– Outcomes measured via online post-consult forms that Outcomes measured via online post-consult forms that assessed consult purpose, actual and potential impact, assessed consult purpose, actual and potential impact, satisfaction, time spent searching, and other variables. satisfaction, time spent searching, and other variables.

• ResultsResults– 226 consults made during 19-month study period. 226 consults made during 19-month study period. – Clinicians primarily made requests in order to update Clinicians primarily made requests in order to update

themselves (65.0%, 147/226) and were satisfied with themselves (65.0%, 147/226) and were satisfied with the service results (Mean 4.52 of possible 5.0, SD 0.94).the service results (Mean 4.52 of possible 5.0, SD 0.94).

– Intention to treat (ITT) analyses showed that consults in Intention to treat (ITT) analyses showed that consults in the CICS Provided condition had a greater actual and the CICS Provided condition had a greater actual and potential impact on clinical actions and clinician potential impact on clinical actions and clinician satisfaction than No CICS consults. satisfaction than No CICS consults.

Clinical Decision Support for Clinical Decision Support for ProvidersProviders• ResultsResults

– Evidence provided primarily impacted the use of a new or Evidence provided primarily impacted the use of a new or different treatment (OR 8.19 95% CI 1.04-64.00). different treatment (OR 8.19 95% CI 1.04-64.00).

– Reasons for no or little impact included a lack of evidence Reasons for no or little impact included a lack of evidence addressing the issue or that the clinician was already addressing the issue or that the clinician was already implementing the practices indicated by the evidence.implementing the practices indicated by the evidence.

• ConclusionsConclusions – Clinical decision-making, particularly regarding treatment Clinical decision-making, particularly regarding treatment

issues, was impacted by the service. issues, was impacted by the service. • ImpactImpact

– Programs such as the CICS may provide an effective tool for Programs such as the CICS may provide an effective tool for facilitating integration of research evidence into facilitating integration of research evidence into management of patient care and may foster clinicians' management of patient care and may foster clinicians' engagement with the biomedical literature. engagement with the biomedical literature.

Clinical Decision Support for Clinical Decision Support for PatientsPatients• Reference 1Reference 1

– Persell et al. Jt Comm J Qual Patient Saf. 2008 Feb;34(2):98-Persell et al. Jt Comm J Qual Patient Saf. 2008 Feb;34(2):98-105. [Northwestern Univ, Chicago] 105. [Northwestern Univ, Chicago]

• TitleTitle– Patient-directed intervention versus clinician reminders alone Patient-directed intervention versus clinician reminders alone

to improve aspirin use in diabetes: a cluster randomized trial.to improve aspirin use in diabetes: a cluster randomized trial.• AimAim

– To determine whether a patient mailing plus nurse telephone To determine whether a patient mailing plus nurse telephone call is more effective than standard CDSS reminders to call is more effective than standard CDSS reminders to physicians for prescribing ASA to diabetics. physicians for prescribing ASA to diabetics.

• MethodsMethods– Cluster-randomized design, 19 physicians caring for 334 eligible Cluster-randomized design, 19 physicians caring for 334 eligible

patients at least 40 years of age randomized. patients at least 40 years of age randomized. – All clinicians received computerized reminders at office visits. All clinicians received computerized reminders at office visits.

Clinical Decision Support for Clinical Decision Support for PatientsPatients• Methods, cont’dMethods, cont’d

– Intervention physicians received e-mails asking Intervention physicians received e-mails asking whether aspirin was indicated for each patient. whether aspirin was indicated for each patient.

– If so, patients received a mailing and nurse telephone If so, patients received a mailing and nurse telephone call addressing aspirin. call addressing aspirin.

– Primary outcome was self-reported regular aspirin Primary outcome was self-reported regular aspirin use. use.

• ResultsResults– Outcome assessment telephone interviews completed Outcome assessment telephone interviews completed

for 242 (72.5%) patients. for 242 (72.5%) patients. – At follow-up, aspirin use was reported by 60 (46%) of At follow-up, aspirin use was reported by 60 (46%) of

the 130 intervention patients and 44 (39%) of the 112 the 130 intervention patients and 44 (39%) of the 112 reminder-only patients, a nonsignificant difference. reminder-only patients, a nonsignificant difference.

Clinical Decision Support for Clinical Decision Support for PatientsPatients

• Results, cont’dResults, cont’d– In subgroup reporting no aspirin use at baseline and In subgroup reporting no aspirin use at baseline and

no contraindications, 33 (43%) of the 76 intervention no contraindications, 33 (43%) of the 76 intervention and 22 (30%) of the 74 reminder-only patients began and 22 (30%) of the 74 reminder-only patients began using aspirin (P = .013).using aspirin (P = .013).

• ConclusionsConclusions– A patient-directed intervention modestly increased A patient-directed intervention modestly increased

aspirin use among diabetes patients beyond that aspirin use among diabetes patients beyond that achieved using computerized clinician reminders for achieved using computerized clinician reminders for ideal candidates. ideal candidates.

– Obstacles included difficulty contacting patients, real Obstacles included difficulty contacting patients, real or perceived contraindications, and failure to follow or perceived contraindications, and failure to follow the nurse's advice.the nurse's advice.


• ImpactImpact– Person-intensive best practice strategies, like Person-intensive best practice strategies, like

automated CDSS’s, encounter diminishing automated CDSS’s, encounter diminishing returns vs. ideal guidelines and outcomesreturns vs. ideal guidelines and outcomes


– Ten Wolde GB et al. Addiction. 2008 Apr;103(4):662-70. [Leiden Univ, Ten Wolde GB et al. Addiction. 2008 Apr;103(4):662-70. [Leiden Univ, Netherlands]Netherlands]

• TitleTitle– Long-term effectiveness of computer-generated tailored patient Long-term effectiveness of computer-generated tailored patient

education on benzodiazepines: a randomized controlled trial.education on benzodiazepines: a randomized controlled trial.• AimAim

– To examined the long-term effectiveness of a tailored patient To examined the long-term effectiveness of a tailored patient education intervention on benzodiazepine use. education intervention on benzodiazepine use.

• MethodsMethods– Controlled trial with three arms, comparing (i) a single tailored letter; (ii) Controlled trial with three arms, comparing (i) a single tailored letter; (ii)

a multiple tailored letters and (iii) a general practitioner letter. More a multiple tailored letters and (iii) a general practitioner letter. More information in tailored letters.information in tailored letters.

– 508 Pts using benzodiazepines recruited by their general practitioners 508 Pts using benzodiazepines recruited by their general practitioners and assigned randomly to one of the three groups. and assigned randomly to one of the three groups.

– Post-test took place after 12 months. Post-test took place after 12 months.

Clinical Decision Support for Clinical Decision Support for PatientsPatients• ResultsResults

– Participants receiving tailored interventions were twice Participants receiving tailored interventions were twice as likely to have quit benzodiazepine use compared to as likely to have quit benzodiazepine use compared to the general practitioner letter. the general practitioner letter.

– Among participants with the intention to discontinue Among participants with the intention to discontinue usage at baseline, both tailored interventions led to high usage at baseline, both tailored interventions led to high percentages of those who actually discontinued usage percentages of those who actually discontinued usage (single tailored intervention 51.7%; multiple tailored (single tailored intervention 51.7%; multiple tailored intervention 35.6%; general practitioner letter 14.5%). intervention 35.6%; general practitioner letter 14.5%).

• ConclusionsConclusions – Tailored patient education can be an effective tool for Tailored patient education can be an effective tool for

reducing benzodiazepine use, and can be implemented reducing benzodiazepine use, and can be implemented easily.easily.


• ImpactImpact– Adds to literature on CDS for patients that Adds to literature on CDS for patients that

suggests it is easier to get patients to stop suggests it is easier to get patients to stop than start medications.than start medications.


– Kypri K et al. Arch Intern Med. 2008 Mar 10;168(5):530-6. Kypri K et al. Arch Intern Med. 2008 Mar 10;168(5):530-6. [Univ. Newcastle, New South Wales, Australia][Univ. Newcastle, New South Wales, Australia]

• TitleTitle– Randomized controlled trial of web-based alcohol screening Randomized controlled trial of web-based alcohol screening

and brief intervention in primary care.and brief intervention in primary care.• AimAim

– To determine whether an electronic Screening and Brief To determine whether an electronic Screening and Brief Intervention (e-SBI) reduces hazardous drinking. Intervention (e-SBI) reduces hazardous drinking.

• MethodsMethods– RCT in a university primary health care service. RCT in a university primary health care service. – 975 students (age range, 17-29 years) screened using the Alcohol 975 students (age range, 17-29 years) screened using the Alcohol

Use Disorders Identification Test (AUDIT). Use Disorders Identification Test (AUDIT). – 599 students (61%) scored in hazardous or harmful range599 students (61%) scored in hazardous or harmful range

Clinical Decision Support for Clinical Decision Support for PatientsPatients• MethodsMethods

– 576 (300 women) in high risk group consented and were 576 (300 women) in high risk group consented and were randomized to receive an information pamphlet (control group), randomized to receive an information pamphlet (control group), a Web-based motivational intervention (single-dose e-SBI a Web-based motivational intervention (single-dose e-SBI group), or a Web-based motivational intervention with further group), or a Web-based motivational intervention with further interventions 1 and 6 months later (multidose e-SBI group). interventions 1 and 6 months later (multidose e-SBI group).

– Measures: self-reported alcohol consumption at 12 monthsMeasures: self-reported alcohol consumption at 12 months

• ResultsResults– Single-dose e-SBI group at 6 months reported a lower Single-dose e-SBI group at 6 months reported a lower

frequency of drinking, less total consumption, and fewer frequency of drinking, less total consumption, and fewer academic problems that were sustained at 12 months. academic problems that were sustained at 12 months.

– Multidose e-SBI group at 6 months reported same plus Multidose e-SBI group at 6 months reported same plus modestly reduced episodic heavy drinking (NS), sustained at 12 modestly reduced episodic heavy drinking (NS), sustained at 12 months.months.


• ConclusionsConclusions– Single-dose e-SBI reduces hazardous drinking, Single-dose e-SBI reduces hazardous drinking,

and the effect lasts 12 months. and the effect lasts 12 months. – Additional sessions seem not to enhance the Additional sessions seem not to enhance the

effect. effect.

• ImpactImpact – Adds to literature that college students are a Adds to literature that college students are a

unique population willing to report hazardous unique population willing to report hazardous behaviors and respond to information behaviors and respond to information interventions directed at reducing those interventions directed at reducing those behaviors.behaviors.


– Matheny ME et al. Arch Intern Med. 2007 Nov 12;167(20):2233-9. Matheny ME et al. Arch Intern Med. 2007 Nov 12;167(20):2233-9. [Brigham & Women’s Hospital, Boston][Brigham & Women’s Hospital, Boston]

• TitleTitle– Impact of an automated test results management system on Impact of an automated test results management system on

patients' satisfaction about test result communication.patients' satisfaction about test result communication.• AimAim

– To assess the impact of physicians' use of a test results To assess the impact of physicians' use of a test results management tool embedded in an electronic health record on management tool embedded in an electronic health record on patient satisfaction with test result communication. patient satisfaction with test result communication.

• MethodsMethods– Cluster-randomized, trial of 570 patient encounters in 26 outpatient Cluster-randomized, trial of 570 patient encounters in 26 outpatient

primary care practicesprimary care practices– Physicians in intervention practices were trained, given access to test Physicians in intervention practices were trained, given access to test

results management tool with imbedded patient notification functions. results management tool with imbedded patient notification functions.


– Patient satisfaction surveys conducted by telephone after the Patient satisfaction surveys conducted by telephone after the patient underwent the test and were administered before and patient underwent the test and were administered before and after the intervention in both arms. after the intervention in both arms.

• ResultsResults– The survey response rate after successful patient contact was The survey response rate after successful patient contact was

74.2% (570/768). 74.2% (570/768). – After adjusting for patient age, sex, race, socioeconomic After adjusting for patient age, sex, race, socioeconomic

status, and insurance type, the intervention significantly status, and insurance type, the intervention significantly increased patient satisfaction with test results communication increased patient satisfaction with test results communication (odds ratio, 2.35; 95% confidence interval, 1.05-5.25; P = .03) (odds ratio, 2.35; 95% confidence interval, 1.05-5.25; P = .03) and more satisfied with information given them for medical and more satisfied with information given them for medical treatments and conditions regarding their results (odds ratio, treatments and conditions regarding their results (odds ratio, 3.45; 95% confidence interval, 1.30-9.17; P = .02). 3.45; 95% confidence interval, 1.30-9.17; P = .02).


• ConclusionsConclusions– Automated test results management Automated test results management

system can improve patient satisfaction system can improve patient satisfaction with communication of test results ordered with communication of test results ordered by their primary care provider and by their primary care provider and

– can improve patient satisfaction with the can improve patient satisfaction with the communication of information regarding communication of information regarding their condition and treatment plans. their condition and treatment plans.

• ImpactImpact – Knowledge is power and contributes to Knowledge is power and contributes to

customer satisfaction in healthcare.customer satisfaction in healthcare.


– Preibe et al. Br J Psychiatry. 2007 Nov;191:420-6. [University of Preibe et al. Br J Psychiatry. 2007 Nov;191:420-6. [University of London, London, UK]London, London, UK]

• TitleTitle– Structured patient-clinician communication and 1-year outcome in Structured patient-clinician communication and 1-year outcome in

community mental healthcare: cluster randomized controlled trial.community mental healthcare: cluster randomized controlled trial.• AimAim

– To test a computer-mediated intervention structuring patient-To test a computer-mediated intervention structuring patient-clinician dialogue (DIALOG) focusing on patients' quality of life clinician dialogue (DIALOG) focusing on patients' quality of life and needs for care. and needs for care.

• MethodsMethods– Cluster-randomized, trial of 134 providers in six countries were Cluster-randomized, trial of 134 providers in six countries were

allocated to DIALOG or treatment as usual; 507 people with allocated to DIALOG or treatment as usual; 507 people with schizophrenia or related disorders included.schizophrenia or related disorders included.


– Every 2 months for 1 year, clinicians asked patients to rate Every 2 months for 1 year, clinicians asked patients to rate satisfaction with quality of life and treatment, and request satisfaction with quality of life and treatment, and request additional or different support. additional or different support.

– Responses fed back immediately in screen displays, Responses fed back immediately in screen displays, compared with previous ratings and discussed. compared with previous ratings and discussed.

– Primary outcome was subjective quality of life, secondary Primary outcome was subjective quality of life, secondary outcomes were unmet needs and treatment satisfaction. outcomes were unmet needs and treatment satisfaction.

• ResultsResults– Of 507 patients, 56 lost to follow-up and 451 were included Of 507 patients, 56 lost to follow-up and 451 were included

in intention-to-treat analyses. in intention-to-treat analyses. – Patients receiving the DIALOG intervention had better Patients receiving the DIALOG intervention had better

subjective quality of life, fewer unmet needs and higher subjective quality of life, fewer unmet needs and higher treatment satisfaction after 12 months. treatment satisfaction after 12 months.


• ConclusionsConclusions– Structuring patient-clinician dialogue to Structuring patient-clinician dialogue to

focus on patients' views positively focus on patients' views positively influenced quality of life, needs for care and influenced quality of life, needs for care and treatment satisfaction. treatment satisfaction.

• ImpactImpact – CDSS tools that facilitate communication CDSS tools that facilitate communication

complement those that provide information complement those that provide information from data/knowledge sources.from data/knowledge sources.

New CDSS RCTs showing no New CDSS RCTs showing no difference for intervention vs. difference for intervention vs.

controlcontrol1.1. Matheny ME et al. Matheny ME et al. A randomized trial of electronic A randomized trial of electronic

clinical reminders to improve medication laboratory clinical reminders to improve medication laboratory monitoring.monitoring. J Am Med Inform Assoc. 2008 Jul- J Am Med Inform Assoc. 2008 Jul-Aug;15(4):424-9. [Brigham & Women’s, Boston]Aug;15(4):424-9. [Brigham & Women’s, Boston]

2.2. Hicks LS. Hicks LS. Impact of computerized decision support on Impact of computerized decision support on blood pressure management and control: a randomized blood pressure management and control: a randomized controlled trial.controlled trial. J Gen Intern Med. 2008 Apr;23(4):429- J Gen Intern Med. 2008 Apr;23(4):429-41. [Brigham & Women’s, Boston]41. [Brigham & Women’s, Boston]

3.3. Tamblyn R et al. Tamblyn R et al. A randomized trial of the effectiveness A randomized trial of the effectiveness of on-demand versus computer-triggered drug decision of on-demand versus computer-triggered drug decision support in primary care.support in primary care. J Am Med Inform Assoc. 2008 J Am Med Inform Assoc. 2008 Jul-Aug;15(4):430-8. [McGill University, Montreal, Jul-Aug;15(4):430-8. [McGill University, Montreal, Canada]Canada]

New CDSS RCTs showing no New CDSS RCTs showing no difference for intervention vs. difference for intervention vs.

controlcontrol4.4. Thomas KG et al. Thomas KG et al. Use of a registry-generated audit, Use of a registry-generated audit, feedback, and patient reminder intervention in an feedback, and patient reminder intervention in an internal medicine resident clinic--a randomized trial.internal medicine resident clinic--a randomized trial. J Gen Intern Med. 2007 Dec;22(12):1740-4. [Mayo J Gen Intern Med. 2007 Dec;22(12):1740-4. [Mayo Clinic]Clinic]

5.5. Harari D et al. Harari D et al. Promotion of health in older people: a Promotion of health in older people: a randomized controlled trial of health risk appraisal in randomized controlled trial of health risk appraisal in British general practice.British general practice. Age Ageing. 2008 Age Ageing. 2008 Sep;37(5):565-71 [St Thomas Hospital, London, UK]Sep;37(5):565-71 [St Thomas Hospital, London, UK] - computerized health risk appraisal & action plan - computerized health risk appraisal & action plan

6.6. Hansagi H et al. Hansagi H et al. Is information sharing between the Is information sharing between the emergency department and primary care useful to emergency department and primary care useful to the care of frequent emergency department users?the care of frequent emergency department users? Eur J Emerg Med. 2008 Feb;15(1):34-9. [Karolinska Eur J Emerg Med. 2008 Feb;15(1):34-9. [Karolinska Univ, Sweden] – case notes of ED forwarded to PMDsUniv, Sweden] – case notes of ED forwarded to PMDs

Personal Health RecordsPersonal Health Records

Personal Health RecordsPersonal Health Records• Reference 1Reference 1

– Grant RW et al. Arch Intern Med. 2008 Sep 8;168(16):1776-82. Grant RW et al. Arch Intern Med. 2008 Sep 8;168(16):1776-82. [Mass General/Partners, Boston][Mass General/Partners, Boston]

• TitleTitle– Practice-linked online personal health records for type 2 diabetes Practice-linked online personal health records for type 2 diabetes

mellitus: a randomized controlled trial.mellitus: a randomized controlled trial.• AimAim

– To evaluate effects of web-based PHR linked to EMR on Type 2 To evaluate effects of web-based PHR linked to EMR on Type 2 diabetes care. diabetes care.

• MethodsMethods– randomized 11 primary care practices. randomized 11 primary care practices. – Intervention practices received access to a DM-specific PHR that Intervention practices received access to a DM-specific PHR that

imported clinical and medications data, provided patient-tailored imported clinical and medications data, provided patient-tailored decision support, and enabled the patient to author a "Diabetes Care decision support, and enabled the patient to author a "Diabetes Care Plan" for electronic submission to their physician prior to upcoming Plan" for electronic submission to their physician prior to upcoming appointments. appointments.

Personal Health RecordsPersonal Health Records• Methods, cont’dMethods, cont’d

– Active control practices received a PHR to update and submit Active control practices received a PHR to update and submit family history and health maintenance information. All family history and health maintenance information. All patients attending these practices were encouraged to sign up patients attending these practices were encouraged to sign up for online access.for online access.

• ResultsResults– 244 patients with DM enrolled (37% of the eligible population 244 patients with DM enrolled (37% of the eligible population

with registered online access, 4% of the overall population of with registered online access, 4% of the overall population of patients with DM). patients with DM).

– Study participants were younger (mean age, 56.1 years vs Study participants were younger (mean age, 56.1 years vs 60.3 years; P < .001) and lived in higher-income 60.3 years; P < .001) and lived in higher-income neighborhoods (median income, $53,784 vs $49,713; P neighborhoods (median income, $53,784 vs $49,713; P < .001) but had similar baseline glycemic control compared < .001) but had similar baseline glycemic control compared with nonparticipants.with nonparticipants.

Personal Health RecordsPersonal Health Records• ResultsResults

– More patients in the intervention arm had their DM More patients in the intervention arm had their DM treatment regimens adjusted (53% vs 15%; P < .001) treatment regimens adjusted (53% vs 15%; P < .001) compared with active controls. compared with active controls.

– No significant differences in risk factor control between No significant differences in risk factor control between study arms after 1 year (P = .53). study arms after 1 year (P = .53).

• ConclusionsConclusions– Pre-visit use of online PHR linked to the EMR increased Pre-visit use of online PHR linked to the EMR increased

rates of DM-related medication adjustment. rates of DM-related medication adjustment. – Low rates of online patient account registration and Low rates of online patient account registration and

good baseline control among participants limited the good baseline control among participants limited the intervention's impact on overall risk factor control. intervention's impact on overall risk factor control.

Personal Health RecordsPersonal Health Records

• ImpactImpact– Motivated, engaged patients with Motivated, engaged patients with

personal resources constitute the personal resources constitute the majority of PHR and portal users. majority of PHR and portal users. These well-educated ‘good patients’ These well-educated ‘good patients’ can make it difficult to detect can make it difficult to detect outcomes differences due to high outcomes differences due to high baseline compliance.baseline compliance.

TelemedicineTelemedicine


10 new RCTs published 10 new RCTs published

November 2007 – October November 2007 – October 20082008

•3 hypertension

•1 each diabetes care, stroke, coronary disease, heart failure, transplantation follow-up, implantable cardioverter, robotic telerounding

• 3 RCTs on hypertensiom 3 RCTs on hypertensiom

– Green BB, et al. Green BB, et al. Effectiveness of home blood pressure Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial.hypertension control: a randomized controlled trial. JAMA. JAMA. 2008 Jun 25;299(24):2857-67. [Group Health, Seattle]2008 Jun 25;299(24):2857-67. [Group Health, Seattle]

– Santamore WP et al. Santamore WP et al. Accuracy of blood pressure Accuracy of blood pressure measurements transmitted through a telemedicine measurements transmitted through a telemedicine system in underserved populations.system in underserved populations. Telemed J E Health. Telemed J E Health. 2008 May;14(4):333-8. [Temple Univ, Philadelphia]2008 May;14(4):333-8. [Temple Univ, Philadelphia]

– Madsen LB et al. Madsen LB et al. Blood pressure control during Blood pressure control during telemonitoring of home blood pressure. A randomized telemonitoring of home blood pressure. A randomized controlled trial during 6 months.controlled trial during 6 months. Blood Press. Blood Press. 2008;17(2):78-86. [Aarhus Univ, Denmark]2008;17(2):78-86. [Aarhus Univ, Denmark]


• MethodsMethods– Group Health Study: 778 hypertensive Pts in 3 Group Health Study: 778 hypertensive Pts in 3

grps : use secure website +/- pharmacist web grps : use secure website +/- pharmacist web communication vs. usual care. Outcome communication vs. usual care. Outcome variable: Percent of Pts with controlled BP at 12 variable: Percent of Pts with controlled BP at 12 months months

– Temple study: 464 hypertensive pts given Temple study: 464 hypertensive pts given recording sphygmomanometer. Entered BP recording sphygmomanometer. Entered BP reading on website, compared to downloaded reading on website, compared to downloaded BP values at clinic visits.BP values at clinic visits.

– Denmark study: 236 hypertensive pts Denmark study: 236 hypertensive pts randomized to entering BP into PDA randomized to entering BP into PDA synchronized over net, with web provider-pt synchronized over net, with web provider-pt feedback. Outcome variable: mean systolic BP feedback. Outcome variable: mean systolic BP change over 6 months.change over 6 months.


• ResultsResults– Group Health Study found web + pharmacist Group Health Study found web + pharmacist

care increased numbers of Pts with controlled care increased numbers of Pts with controlled BP but not web alone vs. standard care.BP but not web alone vs. standard care.

– Temple study found Pt entered accurate BP Temple study found Pt entered accurate BP readings, including underserved and low readings, including underserved and low literacy patientsliteracy patients

– Denmark study found both groups had BP fall Denmark study found both groups had BP fall during study, telemonitoring ‘as good as’ during study, telemonitoring ‘as good as’ office visit monitoring office visit monitoring

• ImpactImpact– Adds to substantial literature showing Adds to substantial literature showing

therapeutic equivalency of telemedicine vs. in therapeutic equivalency of telemedicine vs. in person monitoring of chronic conditions.person monitoring of chronic conditions.


TelemedicineTelemedicine• Reference 4Reference 4

– Meyer BC et al. Lancet Neurol. 2008 Sep;7(9):787-95. [UC San Meyer BC et al. Lancet Neurol. 2008 Sep;7(9):787-95. [UC San Diego]Diego]

• TitleTitle– Efficacy of site-independent telemedicine in the STRokE DOC trial: Efficacy of site-independent telemedicine in the STRokE DOC trial:

a randomized, blinded, prospective study. a randomized, blinded, prospective study. • AimAim

– To assessed whether telemedicine (real-time, two-way audio and To assessed whether telemedicine (real-time, two-way audio and video) or telephone was superior for decision making regarding video) or telephone was superior for decision making regarding use of thrombolytics in acute stroke. use of thrombolytics in acute stroke.

• MethodsMethods– Stroke patients at four remote sites in California randomized to video and Stroke patients at four remote sites in California randomized to video and

DICOM image telemedicine vs. telephone consultation with neurologists DICOM image telemedicine vs. telephone consultation with neurologists at academic center. at academic center.

– Cases reviewed for correctness of decision regarding use of Cases reviewed for correctness of decision regarding use of thrombolytics and incidence of intracerebral hemorrhagethrombolytics and incidence of intracerebral hemorrhage

TelemedicineTelemedicine• ResultsResults

– 234 patients assessed Jan 2004 – Aug 2007. 111 randomized to 234 patients assessed Jan 2004 – Aug 2007. 111 randomized to each arm, 207 completed study. each arm, 207 completed study.

– Correct treatment decisions were made more often in the Correct treatment decisions were made more often in the telemedicine group than telephone grp 98% vs 82%, p=0.0009).telemedicine group than telephone grp 98% vs 82%, p=0.0009).

– Intravenous thrombolytics were used at an overall rate of 25% (31 Intravenous thrombolytics were used at an overall rate of 25% (31 [28%] telemedicine vs 25 [23%] telephone, 1.3, 0.7-2.5; p=0.43). [28%] telemedicine vs 25 [23%] telephone, 1.3, 0.7-2.5; p=0.43).

– No difference in mortality (1.6, 0.8-3.4; p=0.27) or rates of No difference in mortality (1.6, 0.8-3.4; p=0.27) or rates of intracerebral hemorrhage.intracerebral hemorrhage.

• ConclusionsConclusions– Telemedicine results in more accurate stroke decision makingTelemedicine results in more accurate stroke decision making

• ImpactImpact– Telemedicine useful way to project specialized neurology svcsTelemedicine useful way to project specialized neurology svcs

TelemedicineTelemedicine• Reference 5Reference 5– Shea S, IDEATel Consortium. Trans Am Clin Climatol Assoc. Shea S, IDEATel Consortium. Trans Am Clin Climatol Assoc.

2007;118:289-304. [Columbia Univ, NYC]2007;118:289-304. [Columbia Univ, NYC]• TitleTitle

– The Informatics for Diabetes and Education Telemedicine (IDEATel) The Informatics for Diabetes and Education Telemedicine (IDEATel) project. project.

• AimAim– To comparing telemedicine case management to usual care for To comparing telemedicine case management to usual care for

diabetes in low socioeconomic status patients. diabetes in low socioeconomic status patients. • MethodsMethods

– 1,665 Medicare recipients with diabetes, aged 55 years or greater, living 1,665 Medicare recipients with diabetes, aged 55 years or greater, living in federally designated medically underserved areas of New York State. in federally designated medically underserved areas of New York State.

– Specialized home telemedicine unit with web-enabled computer, video, Specialized home telemedicine unit with web-enabled computer, video, glucose and BP monitoring, upload to Columbia EMRglucose and BP monitoring, upload to Columbia EMR

– Primary endpoints were HgbA1c, blood pressure, and low density Primary endpoints were HgbA1c, blood pressure, and low density lipoprotein (LDL) cholesterol levels. lipoprotein (LDL) cholesterol levels.

TelemedicineTelemedicine• ResultsResults

– In New York City, 98% of participants were black or In New York City, 98% of participants were black or Hispanic, 69% were Medicaid-eligible, and 93% reported Hispanic, 69% were Medicaid-eligible, and 93% reported annual household income < or =$20,000. annual household income < or =$20,000.

– In upstate New York, 91% were white, 14% Medicaid In upstate New York, 91% were white, 14% Medicaid eligible, and 50% reported annual household income < or eligible, and 50% reported annual household income < or =$20,000. =$20,000.

– 95% of NYC participants did not know how to use a 95% of NYC participants did not know how to use a computercomputer

– BP, LDL, and HBA1C all decreased in intervention group BP, LDL, and HBA1C all decreased in intervention group relative to usual care group at 1 year of follow-up.relative to usual care group at 1 year of follow-up.

– Same effects observed in urban and rural populationsSame effects observed in urban and rural populations– User satisfaction high.User satisfaction high.

TelemedicineTelemedicine• ConclusionsConclusions

– Telemedicine is an effective method for Telemedicine is an effective method for translating modern approaches to disease translating modern approaches to disease management into effective care for management into effective care for underserved populations.underserved populations.

• ImpactImpact– Telemedicine effects seen in low income, Telemedicine effects seen in low income,

non-computer literate populationnon-computer literate population– No analysis of cost-effectiveness providedNo analysis of cost-effectiveness provided

TelemedicineTelemedicine• Reference 6Reference 6– Ellison LM et al. Arch Surg. 2007 Dec;142(12):1177-81 Ellison LM et al. Arch Surg. 2007 Dec;142(12):1177-81

[Penobscot Bay Medical Center, Rockport, ME][Penobscot Bay Medical Center, Rockport, ME]• TitleTitle

– Postoperative robotic telerounding: a multicenter randomized Postoperative robotic telerounding: a multicenter randomized assessment of patient outcomes and satisfaction. assessment of patient outcomes and satisfaction.

• AimAim– To assess patient safety and satisfaction when robotic To assess patient safety and satisfaction when robotic

videoconferencing (telerounding) is used in the postoperative videoconferencing (telerounding) is used in the postoperative setting. setting.

• MethodsMethods– 270 adults undergoing a urologic procedure requiring a 270 adults undergoing a urologic procedure requiring a

hospital stay of 24 to 72 hours were randomized to receive hospital stay of 24 to 72 hours were randomized to receive either traditional bedside rounds or robotic telerounds.either traditional bedside rounds or robotic telerounds.

TelemedicineTelemedicine• Methods, cont’dMethods, cont’d

– The primary outcome measure was postoperative patient The primary outcome measure was postoperative patient morbidity. morbidity.

– Secondary outcomes were patient-reported satisfaction and Secondary outcomes were patient-reported satisfaction and hospital length of stay. hospital length of stay.

– Other variables assessed included demographics, procedure, Other variables assessed included demographics, procedure, operative time, estimated blood loss, and mortality. operative time, estimated blood loss, and mortality.

– Patients also completed a validated satisfaction instrument 2 Patients also completed a validated satisfaction instrument 2 weeks after hospital discharge.weeks after hospital discharge.

• ResultsResults– Morbidity rates and length of stay were similar between the Morbidity rates and length of stay were similar between the

study arms (standard rounds vs telerounds: 16% vs 13%; P study arms (standard rounds vs telerounds: 16% vs 13%; P = .64, 2.8 days LOS both groups, P=.94). = .64, 2.8 days LOS both groups, P=.94).

– Patient satisfaction was equivalently high in both groups. Patient satisfaction was equivalently high in both groups.

TelemedicineTelemedicine• ConclusionsConclusions

– Robotic telerounds matched the Robotic telerounds matched the performance of standard bedside rounds performance of standard bedside rounds after urologic surgical procedures. after urologic surgical procedures.

• ImpactImpact– Provocative in-hospital telemedicine Provocative in-hospital telemedicine

reportreport– Telemedicine provider skills somewhat Telemedicine provider skills somewhat

different than in person skills; some different than in person skills; some clinicians natural ‘TV doctors’, some notclinicians natural ‘TV doctors’, some not

Telemedicine RCTs with no Telemedicine RCTs with no difference between intervention difference between intervention

and controland control• Dansky et al. Dansky et al. Impact of telehealth on clinical Impact of telehealth on clinical

outcomes in patients with heart failure.outcomes in patients with heart failure. Clin Nurs Res. Clin Nurs Res. 2008 Aug;17(3):182-99. [Penn State] – Home 2008 Aug;17(3):182-99. [Penn State] – Home monitoring vs. F2F care, no sig diff in symptoms or ED monitoring vs. F2F care, no sig diff in symptoms or ED visits/hospitalizations.visits/hospitalizations.

• Leimig R et al. Leimig R et al. Infection, rejection, and Infection, rejection, and hospitalizations in transplant recipients using hospitalizations in transplant recipients using telehealth.telehealth. Prog Transplant. 2008 Jun;18(2):97-102. Prog Transplant. 2008 Jun;18(2):97-102. [Univ Tenn.] – Live interactive sessions w/ specialized [Univ Tenn.] – Live interactive sessions w/ specialized telemedicine equip including physical exam vs. nurse telemedicine equip including physical exam vs. nurse visits. No diff in infections, rejection, hospitalizations.visits. No diff in infections, rejection, hospitalizations.

Practice of InformaticsPractice of Informatics

Practice of InformaticsPractice of Informatics• Reference 1Reference 1

– Love TE et al. J Gen Intern Med. 2008 Apr;23(4):383-91. [Case Love TE et al. J Gen Intern Med. 2008 Apr;23(4):383-91. [Case Western, Cleveland]Western, Cleveland]

• TitleTitle– Electronic medical record-assisted design of a cluster-randomized Electronic medical record-assisted design of a cluster-randomized

trial to improve diabetes care and outcomes.trial to improve diabetes care and outcomes.• AimAim

– To describe the design of a CRT of clinical decision support to To describe the design of a CRT of clinical decision support to improve diabetes care and outcomes. improve diabetes care and outcomes.

• MethodsMethods– EMR-derived Pt characteristics used to partition Pts into groups with EMR-derived Pt characteristics used to partition Pts into groups with

comparable baseline characteristics for two different cluster-comparable baseline characteristics for two different cluster-randomized interventional trials of diabetes care using two different randomized interventional trials of diabetes care using two different EMRs (Systems A and B).EMRs (Systems A and B).

– Measures: distributions of important eligibility and covariates Measures: distributions of important eligibility and covariates compared to traditional means of identifying groupscompared to traditional means of identifying groups

• ResultsResults– In System A, 4,306 patients assigned to 2 groups of In System A, 4,306 patients assigned to 2 groups of

practices; 8,369 patients in system B assigned to 3 groups practices; 8,369 patients in system B assigned to 3 groups of practices.of practices.

– Nearly all baseline outcome variables and covariates were Nearly all baseline outcome variables and covariates were well-balanced, including several not included in the initial well-balanced, including several not included in the initial design. design.

– Study design balance was superior to alternative partitions Study design balance was superior to alternative partitions based on volume, geography or demographics alone. based on volume, geography or demographics alone.

• ConclusionConclusion– EMRs facilitated rigorous CRT design by identifying large EMRs facilitated rigorous CRT design by identifying large

numbers of patients with diabetes and enabling fair numbers of patients with diabetes and enabling fair comparisons through preassignment balancing of practice comparisons through preassignment balancing of practice sites.sites.


• ImpactImpact– In the era of Clinical and Translational In the era of Clinical and Translational

Science Awards (CTSAs) increasingly Science Awards (CTSAs) increasingly sophisticated methods are being sophisticated methods are being developed to data mine EMRs for developed to data mine EMRs for observational studies, eligibility and design observational studies, eligibility and design for interventional studies.for interventional studies.


• Reference 2Reference 2– Bereznicki BJ et al. Med J Aust. 2008 Jul 7;189(1):21-5.. [Univ of Bereznicki BJ et al. Med J Aust. 2008 Jul 7;189(1):21-5.. [Univ of

Tasmania, Australia]Tasmania, Australia]• TitleTitle

– Data-mining of medication records to improve asthma Data-mining of medication records to improve asthma management. management.

• AimAim– To use community pharmacy medication records to identify To use community pharmacy medication records to identify

patients whose asthma not well managed, implement and patients whose asthma not well managed, implement and evaluate a multidisciplinary educational intervention to evaluate a multidisciplinary educational intervention to improve asthma management.improve asthma management.

• MethodsMethods– 42 pharmacies ran software application to "data-mine" med 42 pharmacies ran software application to "data-mine" med

records, generating a list of patients w/ >= 3 canisters of records, generating a list of patients w/ >= 3 canisters of inhaled short-acting beta(2)-agonists in the preceding 6 inhaled short-acting beta(2)-agonists in the preceding 6 months. months.


• Methods, cont’dMethods, cont’d– Pts randomized to be contacted by the Pts randomized to be contacted by the

community pharmacist via mail, and sent community pharmacist via mail, and sent educational material & letter encouraging educational material & letter encouraging them to see their general practitioner for an them to see their general practitioner for an asthma management review.asthma management review.

– Outcome variable: ratio of preventer meds Outcome variable: ratio of preventer meds (steroids) to reliever meds (beta2 agonists) (steroids) to reliever meds (beta2 agonists)

• ResultsResults– 702 intervention and 849 control Pts. 702 intervention and 849 control Pts. – Threefold increase in preventer-reliever Threefold increase in preventer-reliever

ratio in intervention vs. control groupratio in intervention vs. control group


• ConclusionConclusion– Community pharmacy medication Community pharmacy medication

records can be effectively used to records can be effectively used to identify patients with suboptimal asthma identify patients with suboptimal asthma management, who can then be referred management, who can then be referred to their GP for reviewto their GP for review

• ImpactImpact– Similar to post-Katrina experience in US, Similar to post-Katrina experience in US,

commercial pharmacy records can be commercial pharmacy records can be merged and data mined to improve caremerged and data mined to improve care


• Reference 3Reference 3– Meystre SM, Huag PJ. Int J Med Inform. 2008 Sep;77(9):602-Meystre SM, Huag PJ. Int J Med Inform. 2008 Sep;77(9):602-

12. [Univ of Utah]12. [Univ of Utah]• TitleTitle

– Randomized controlled trial of an automated problem list Randomized controlled trial of an automated problem list with improved sensitivity. with improved sensitivity.

• AimAim– To improve the completeness and timeliness of an To improve the completeness and timeliness of an

electronic problem list.electronic problem list.• MethodsMethods

– Authors developed a system using Natural Language Authors developed a system using Natural Language Processing (NLP) to automatically extract potential medical Processing (NLP) to automatically extract potential medical problems from clinical, free-text documentsproblems from clinical, free-text documents

– Problems then proposed for inclusion in an electronic Problems then proposed for inclusion in an electronic problem list management application. problem list management application.


• Methods, cont’dMethods, cont’d– 247 patients enrolled intensive care unit and IN 247 patients enrolled intensive care unit and IN

cardiovascular surgery unit)cardiovascular surgery unit)– All patients had their documents analyzed by the All patients had their documents analyzed by the

system, but the medical problems discovered were system, but the medical problems discovered were only proposed in the problem list for intervention only proposed in the problem list for intervention patients. patients.

– Measured the sensitivity, specificity, positive and Measured the sensitivity, specificity, positive and negative predictive values, likelihood ratios and negative predictive values, likelihood ratios and the timeliness of the problem lists. the timeliness of the problem lists.

• ResultsResults– System increased sensitivity of problem lists in System increased sensitivity of problem lists in

ICU, from 9% to 41%, and to 77% if problems ICU, from 9% to 41%, and to 77% if problems automatically proposed but not acknowledged also automatically proposed but not acknowledged also considered. considered.


• Results, cont’dResults, cont’d– Timeliness of addition of problems to the Timeliness of addition of problems to the

list was greatly improved, with a time list was greatly improved, with a time between a problem's first mention in a between a problem's first mention in a clinical document and its addition to the clinical document and its addition to the problem list reduced from about 6 days to problem list reduced from about 6 days to less than 2 days. less than 2 days.

– No significant effect was observed in the No significant effect was observed in the cardiovascular surgery unit.cardiovascular surgery unit.

• ImpactImpact– NLP is coming of age for extraction of NLP is coming of age for extraction of

structured content from unstructured clinical structured content from unstructured clinical documents.documents.


Top Ten List of Top Ten List of Notable Events Notable Events

in the Past 12 monthsin the Past 12 months

““Top Ten” EventsTop Ten” Events

#5 - CMS Medicare Improvements Act of #5 - CMS Medicare Improvements Act of 2008 pays more 2008 pays more for e-prescribing for e-prescribing

““Top Ten” EventsTop Ten” Events#5 - CMS Medicare Improvements Act of 2008 pays more #5 - CMS Medicare Improvements Act of 2008 pays more

for e-prescribing for e-prescribing

#4 – Explosion of molecular data#4 – Explosion of molecular data

• 22ndnd, 3, 3rdrd, and 4, and 4thth full full human genomes online human genomes online in past yearin past year

• $500 personal $500 personal genome expected in 3 genome expected in 3 yearsyears

• Proteomic labs Proteomic labs generating a terabyte of generating a terabyte of mass spec data per mass spec data per experimentexperiment

• Straining Straining communication, communication, archiving and analysis archiving and analysis infrastructureinfrastructure

““Top Ten” EventsTop Ten” Events#5 - CMS Medicare Improvements Act of 2008 pays more #5 - CMS Medicare Improvements Act of 2008 pays more

for e-prescribing for e-prescribing


#3 - FDA Sentinel Initiative launched, May 2008#3 - FDA Sentinel Initiative launched, May 2008

““Top Ten” EventsTop Ten” Events

#5 - CMS Medicare Improvements Act of 2008 pays #5 - CMS Medicare Improvements Act of 2008 pays more more for e-prescribing for e-prescribing


#3 - FDA Sentinel Initiative launched#3 - FDA Sentinel Initiative launched

#2 – NIH Public Access policy becomes mandatory #2 – NIH Public Access policy becomes mandatory 12/200712/2007

And the #1 top event of And the #1 top event of 2008 is…2008 is…

““Top Ten” EventsTop Ten” Events#5 - CMS Medicare Improvements Act of 2008 pays #5 - CMS Medicare Improvements Act of 2008 pays

more more for e-prescribing for e-prescribing


#3 - FDA Sentinel Initiative launched#3 - FDA Sentinel Initiative launched

#2 – NIH Public Access policy becomes mandatory#2 – NIH Public Access policy becomes mandatory

#1 – Obama wins Presidency on platform including #1 – Obama wins Presidency on platform including $50B for$50B for EMR infrastructure EMR infrastructure

The only thing we The only thing we know about the know about the future is that it future is that it will be different.will be different.

Peter Drucker

The Village Inn

The Year in The Year in Review Review Summary…Summary…

biomedical informatics year in review 2008 notable publications and events in informatics during...

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