The traditional face-to-face doctor–patient relationship is the core of conventional medical practice. One key aspect of this changing relationship is the increasing dependency on asynchronous data collection in clinical consultations. Such electronic communications and data streams may be numeric, text-based, audio, digitized still pictures, video and radiologic, as well as emanating from multiple medical devices. While asynchronous medicine may be established in specialties like radiology and dermatology, there is little research regarding the use of asynchronous medicine in areas of medicine that traditionally rely on the physical doctor–patient interaction such as primary care, internal medicine, geriatrics, and psychiatry. The practice of psychiatry stands out as a discipline that is highly dependent on the quality of the physical meeting between the doctor and the patient, yet even in this specialty it is possible to utilize asynchronous medicine for some types of psychiatric consultations....

Disruptive innovation: the future of healthcare?

The operational aspects, application areas, and results achieved from an integrated surgical suite management information system are described. The system, which has been operating within Henry Ford Hospital in Detroit, Michigan, for 4 years, captures comprehensive data for each surgical episode, performs extensive edits on these data to assure data base integrity, and utilizes this data base in multiple applications. These applications include fixed-format reporting for medical staff and management; ad hoc retrieval capabilities to support research, education, and decision making; and linkage to other hospital systems to reduce both data redundancy and paper flow.

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An integarted surgical suite management information system

In the 1970s, to control costs and comply with Medicare rules, hospitals began to use computer-based systems for utilization review. In the early 1980s, a diagnostic related group (DRG) approach was applied to hospital payments, and increasingly complex data reporting requirements led hospitals to establish quality assurance programs. Medical information, or medical knowledge, databases for clinical decision support (CDS) were developed in the 1980s. The capabilities provided by online real time monitoring, vastly increased data storage, and physician order entry and results reporting (OE/RR) came together in CDS programs in the 2000s; by 2010 most physicians were using systems that provided online practice guidelines as well as clinical reminders and alerts about potential adverse clinical events. These advances build upon techniques from other fields, including artificial intelligence; the emergence of huge clinical databases in the 1990s led to the use of data mining to uncover previously unknown important relationships between clinical data elements, and the use of efficient knowledge discovery algorithms to extract knowledge from data by identifying and describing patterns in a meaningful manner. To support knowledge creation in biomedicine, the National Library of Medicine produces and maintains hundreds of up-to-date scientific databases, including MEDLINE (over 23 million citations with 700,000 posted in 2013 alone), human genome resources, toxicology and environmental databases (searched billions of times a year by millions around the globe).

Decision Support Systems (DSS)

A set of on-line computer programs has been designed and implemented for the acquisition and long-term storage, retrieval, and evaluation of Holter monitoring data. The physician interpreting Holter tapes enters his findings in the computer system using an on-line remote terminal located in the heart station. The programs are available practically around the clock and allow reviewing of individual cases, preparation of printed reports, and fast evaluation of the presence or absence of a number of common findings in the entire data base. Approximately 800 cases have been entered since the initiation of this project in early 1977.

On-line storage, retrieval, and evaluation of long-term electrocardiographic monitoring data.

A set of computer programs collects, processes, and reports Professional Standards Review Organization (PSRO) and utilization data for all inpatients at the Miami Heart Institute. They help reduce the time spent by physicians in PSRO and utilization review activities and ease the clerical work load required to comply with rules and guidelines. Daily printed reports provide attending physicians with their patient census and inform them of the next scheduled PSRO review dates for each of their patients. Reports are produced also for the Utilization Review Committee and the Institute's PSRO office. This set of programs is part of a comprehensive automated hospital information system and has been designed to respond rapidly to the frequent changes in regulations and policies dictated by the administering agency. The PSRO subsystem has been in uninterrupted operation for over 6 years and has mitigated escalating clerical and, therefore, health care costs. Physicians' acceptance of this subsystem has been adequate; however, developmental and maintenance costs are high in comparison with other applications within the hospital information system. This article describes the methodology used in complying with PSRO requirements. It does not attempt to evaluate the impact of PSRO on quality of care or length of hospital stay.

An automated PSRO-utilization review system.

The Miami Heart Institute automation project, conceived as a comprehensive unified hospital information system, has been in continuous development since 1969. As of February 1978, the system supports medical services and laboratories as well as teaching, financial, administrative, and research applications through approximately 100 remote terminals. It is controlled by a single operating system serving interrelated data bases and is available to its users practically 24 hours a day, 7 days a week. The information system transfers data to and from dedicated mini- and microcomputer systems and incorporates digital and analog instrumentation interfaces that include physiologic signal-processing capabilities. Acceptance by user departments ranges from good to excellent, whereas acceptance by the private attending staff at large has been only fair. This report presents a general overview of several major subsystems and discusses advantages and shortcomings of the project.

The Miami Heart Institute information system.

The surgeon (or one of his assistants) enters, in a computer file, information on open-heart surgical procedures through a remote terminal located in the recovery room. Clinical and historical findings, complications occurring during the immediate postoperative period, and postmortem data when applicable are entered in the course of the hospital stay or after discharge. Relevant information entering the computer system in other hospital departments is automatically incorporated in the open-heart surgery file. A final multicopy operative report is printed in the recovery room shortly after the surgical procedure is completed. All information on patients in the file constitutes a permanent and dynamic data base that is accessible at any time from any remote terminal in the hospital computer system. This data base contains an average of 500 items of information per surgical procedure and is available via an on-line retrieval program for both quality control purposes and extrapolation of prognostic data on new patients.

Alberto Budkin

Papers

The Miami Heart Institute information system.

On-line storage, retrieval, and evaluation of long-term electrocardiographic monitoring data.

An automated PSRO-utilization review system.

On-line computer management of cardiac surgical data.