1. Bringing Clinical Information to the Bedside with the World Wide Web James J. Cimino, M.D. Departments of Medicine and Medical Informatics Columbia University

2. First Admission: August, 1983 In August, 1983, a 50 year old male presented to the St. Vincent’s Hospital (NY) emergency room with a scalp laceration due to a falling paint can. The wound was cleaned and sutured, and the patient was given a follow up appointment for surgery clinic. Two weeks later, the patient was seen at the scheduled clinic visit and was found to have delayed healing of one portion of the wound. After several weekly visits, the poorly- healing area was excised and the wound was closed. The patient had a good result and was discharged from further follow up.

3. Second Admission - March, 1984 The patient was brought to the emergency room for recent increasing lethargy. Laboratory evaluation was remarkable only for a calcium of 17 mg/dl. The patient was treated aggressively with hydration and diuretics, but expired shortly after admission. A diagnostic report was received.

4. Prologue as Epilogue The pathology report from the wound revision the previous September included the following phrase: “Metastatic adenocarcinoma of uncertain origin is noted at the tissue margins”

5. What Happened? The surgeons didn’t know to follow up The pathologists assumed someone would read their report No one was making sure that the ball didn’t get dropped

6. How Could Computers Help? The report would not fall through the cracks Route the report to the right person Generate an alert Check to see if someone read the report/alert

7. How Can the Web Help? Ubiquitous (bi-directional) access Bring together information from multiple systems Access to on-line health information resources Integration of information resources and clinical applications

9. Medical Entities Dictionary Patient Database Radiology Pharmacy Laboratory Event Monitor Medical Logic Modules Billing & Financial Database Interface Data Entry & Results Review Research Databases Specialized Encoders MedLEE

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

11. CIS Daily Inquiries (weekdays) March '97 2022 2046 1114 639 700 559 514 104 396 7547 LABRADDEMPATHAdmDischCAROp.PharOther Inquiries/day

12. Physician Use Clinical Information System Utilization Over Time Peak vs. Other hours 0 2000 4000 6000 8000 10000 12000 14000 16000 1990 Sept 1991 Sept 1992 Sept 1993 Sept 1994 Sept 1995 Sept 1996 Sept 1997 # of screens/hour Peak (2-5pm) Normal (8am-2pm) Low (midnight to 8am)

13. Physician Use CIS Utilization House Staff vs. Attendings March 1997 0 10 20 30 40 50 60 70 80 90 100 MEDNEUOBGORTPEDPSYSURUROOTHER % using CIS System House officers Attendings

14. Clinical MLMs: Alerts SUBJECTPERCENT VIEWED VIEWINGS / EVENT EVENTS / MONTH NUMBER OF MLMs positive TB culture73.57.534.31 creatinine rise63.13.1254.11 hypokalemia anddigoxin use57.52.187.13 newborn with HBV positive mother 55.01.912.52 hypokalemia and diuretic use 48.01.6662 renal failure and aminoglycoside use 41.71.6562 renal failure and NSAID use34.81.81392 new anemia32.42.1430.71

15. WebCIS Web-based Clinical Information System For use by clinicians (doctors, nurses, students) Access to all data in the repository Access to on-line information resources

36. Things You Can Do On the Web Read a newspaper Buy groceries Banking Trade stocks Track your Fed Ex package Get health information

37. Health Information You Can Get Medline citations Drug advertisements Quack therapies Viagra prescriptions

38. Health Information You Can’t Get Your cholesterol level Your mammogram report A list of your current medications Advice from your doctor

39. Personal Health Information on the Web Access to your electronic medical record Ability to contribute to your medical record Relevant, reliable, understandable advice Fostering patient-clinician communication

40. PatCIS: An Experiment with Patient Access Funded by the US National Library of Medince Data entry Data review Education Advice “Infobuttons”

68. Potential Areas of Expansion Lab test interpretation Pap smear infobutton Medication lists Advance directives

69. Addressing the Challenges Web access to records Security and confidentiality issues Political issues Ethical issues

70. Ethical Issues Discovery without supervision Misunderstanding and worry Misunderstanding and complacency Patient-clinician communications –better –shorter –worse –longer

71. Conclusions Web access to clinical information is feasible for clinicians and patients The Web offers innovative ways to view data Integration of clinical systems and decision support tools is possible Infrastructure is crucial Cognitive issues are under study