5:30 p.m. Adjourn
2:30 p.m. *j) 2:30 p.m.
MPH.
SECTION
ON
COMPUTERS
& OTHER
TECHNOLOGIES
1996
ANNUAL
MEETING
PROGRAM
October
29,
1996
TUESDAY, OCTOBER 29
H417 Section on Computers and Other Technologies
9:00 a.m-5:30 p.m.
Hynes Convention Center, Room 110
8:00 a.m. Section Business Meeting and Continental
Breakfast
Jerold Aronson, M.D., FAAP
9:00 a.m. Computer Applications to Quality
Im-provement and Quality Assurance (joint
with the Committee on Quality
Improve-ment)
Quality Assurance (QA) and quality im-provement (QI) are becoming increasingly important in pediatric practice, especially in the current healthcare environment with the augmented presence of managed care. The use of information processing and decision support capabilities of the computer will play important roles in facilitating QA and QI. This seminar will begin with an over-view of QI/QA concepts including a discus-sion of the development of performance im-provement measures. We will then look at actual applications of QI/QA techniques us-ing computer-based decision support tools. Finally, the use of computers in pediatric continuing medical education will be dem-onstrated as QI/QA for professional devel-opment.
David Bergman, M.D., FAAP, Charles Homer, M.D., MPH., FAAP, Fred Smith, M.D., FAAP
12:00 p.m. Break for Lunch
(Members are encouraged to attend the
AAP Annual Business Luncheon 12:15-2:15 at Boston Marriott, Grand Ballroom 4th Floor)
Scientific Abstract Session
Computerized Multimedia vs. Printed
Ma-terial for Patient Health Education D. M. Paperny, M.D., FAAP
2) 2:50 p.m. Access Control and Data Integrity in
Med-ical Records
C.
J.
Okstein, M.D., FAAP3) 3:10 p.m. The Clinical Informatics Network (CLINT):
Use in a Pediatric Department
1.
Ohayon, M.D.; K. Langton, M.Sc., BEd.; R. Issenman, M.D., FAAP; R. Hayward, M.D.,4) 3:30 p.m. Telephone Driven, Automated
Prescrip-tion Renewal System (APRS) Using a
Touch Tone Phone and a Fax Machine
E. R. Christophersen, Ph.D., FAPA; M. C. Luxem, Ph.D.
3:50 p.m. Coffee Break
5) 4:10 p.m. Pedlnfo at Age 2: The State of the Pediatric
Internet
S. A. Spooner, M.D.
*Abstract number appears in left column,
6) 4:30 p.m. Guiding Primary Care Providers to Access
Medical Genetics Information
Electrom-cally at the Time of the Patient Encounter
V. K. Proud, M.D., FAAP; E. E. McColligan, MS., M.P.H.
7) 4:50 p.m. Time Trend Monitoring in the Neonatal
Intensive Care Unit Why Doesn’t it Make
a Difference?
Neil McIntosh, D.Sc. (Med); A. Lyon, MB., FRCP; P. Badger
8) 5:10 p.m. Patient Satisfaction With Paper-Based
Ver-sus Personal Digital Assistant-based Sur-vey Completion
K. B. Johnson, M.D., M.S., FAAP; M. D.
Wilson,
M.D., FAAP; S. Arnold; A. Joffe, M.D., FAAP
ABSTRACTS
1
COMPUTERIZED MULTIMEDIA VS PRINTED MATERIAL
FOR PATIENT HEALTH EDUCATION
David M. Paperny M.D. FAAP. Dept. of Pediatrics, Kaiser Perma-nente, and Univ of Hawaii School of Medicine, Honolulu, Hawaii
The AAP Guidelines for Health Supervision recommend age-specific anticipatory guidance and identification of health needs. A multimedia computer program was designed to obtain an accurate, comprehensive behavioral and health history, identify problem areas and health needs, give selective anticipatory guidance, and then provide problem-specific health advice and local referrals. Adoles-cent patients enjoyed anonymously engaging the nonjudgmental computer, which facilitated acceptance of medical advice. Within minutes, the computer completed the interview, printed feedback, dispensed specific handouts and then administered relevant audio-visual selections from a library of succinct high-impact health edu-cation multimedia presentations designed for computer use.
Evaluation ofeducational media used at outpatient pediatric phys-ical exams assessed improvements in users’ knowledge regarding smoking and sex. Test instruments based on the content of each presentation script were developed to assess impact of two different automated interventions. One third of a random sample of 595 anon-ymous adolescent computer users (average age 15.4 years, 51% fe-male) had audio-visual presentations administered; the second matched third had none but were dispensed handouts identical to the scripts, and one third as matched controls were computer users without handouts or presentations. Measures ofsix knowledge items about smoking and sex were separately made on control and two experimental groups.
multimedia advice is a promising intervention for pediatric health promotion.
538 SUPPLEMENT
2
ACCESS CONTROL AND DATA INTEGRITY IN MEDICAL
RECORDS.
Charles
J.
Okstein, MD, FAAP. Department of Pediatrics,Mari-copa Medical Center, Phoenix, AZ, and College of Medicine, Urn-versity of Arizona, Tucson, AZ
We are all consumers of medical services and would like those who treat us to provide appropriate security for our records, many of which contain information we would consider harmful or em-barrassing if inappropriately released. Therefore, medical record security is an issue of concern to everyone.
So much attention has been focused recently on potential secu-rity issues involving computerized patient records (CPRs) that many physicians and administrators do not recognize that most of the same issues exist to a greater extent with conventional paper charts.
Medical record security implies that an active system is in place to prevent the unauthorized disclosure of medical information from a patient’s record except as authorized by the patient and only for purposes authorized by the patient. Security plans need to be tough enough to protect a record from inappropriate use while allowing easy access to those entrusted by the patient to provide him care. Security involves many issues but two of the most fundamental concerns are control of access to the record and maintaining the integrity of the information recorded in the chart.
“Access control” refers to a system that gives certain individuals permission to read or update a medical record, while successfully excluding unauthorized individuals. In conventional systems, a
clerk may monitor who has signed-out a record. CPRS allow
“audit-tracking” of who is reading a particular record page as well as who is modifying it and they prevent unauthorized individuals from viewing selected portions of a record. They can also “au-thenticate” the identity of a user using access codes, passwords, voice recognition, and measurements of other biometric parame-ters, such as fingerprints.
“Information integrity” refers to the ability of a clinic or health care organization to protect a patient record from tampering, mutilation or loss. In some cases, it also relates to the efforts of an organization to ensure that data recorded in a chart is valid
information. CPRS can discourage unauthorized copying of
records and prevent removal or modifications to individual pages, tasks impossible with conventional paper records. CPRS allow physicians to economically create duplicate sets of records for
off-site storage and protection from physical damage in case of natural disaster.
As providers of medical care, we have a moral, ethical and legal obligation to keep confidences entrusted to us by our patients. We must prevent the unauthorized disclosure of information without a patient’s authorization. By almost every standard CPRS surpass paper records in their ability to include systems that limit the likelihood of unauthorized access or tampering.
3
THE CLINICAL INFORMATICS NETWORK (CLINT); USE
IN A PEDIATRIC DEPARTMENT.
Jason Ohayon, MD, Karl Langton, MSc, BEd, Robert Issenman,
MD, FAAP, Robert Hayward, MD, MPH. Dept. of Pediatrics and Dept. of Clinical Epidemiology and Biostatistics, McMaster Uni-versity, and Children’s Hospital at Chedoke-McMaster, Hamilton, ON, Canada.
Background: CLINT, a CLinical Informatics Network, was de-veloped as a PC-based network of a patient database, medical information resource and communication tool for the pediatric staff at Children’s Hospital at Chedoke-McMaster. A menu of 18 on-line information resources, 3 communication tools and a pa-tient database was introduced in December 1995. Twelve stations provide 24 hr. availability on wards and clinics to 15 on-line CD medical texts and 3 journals. CLINT also provides a communica-tion facility for library based Medline, local E-mail and the Inter-net. The hospital’s Electronic Medical Record (EMR), a compre-hensive patient database, is accessible on the same menu. The educational strategy included a presentation at Pediatric Grand Rounds with an initial and 3 month follow-up training session. Identification of a staff and resident “mentor” were an important part of the introductory process.
Methods: A computerized record was maintained for every logon to CLINT. A record of all entries-both as “instances of” and “time per” application was analyzed for all users, for the period of 12/19/95 to 04/26/96. An introductory and interval attitudinal survey were completed on-line by all participants. Informed con-sent was obtained from all participants prior to account activation. There were 52 registered CLINT users, among the 60 pediatric staff and residents, at the commencement of the study.
Results: There were a total of 1262 “sign ons” by all 52 registered individuals for a total of 4445 minutes of use. 87 percent of all staff and residents were logging onto CLINT. Data analysis suggests an average of 24 “sign ons” per individual with a mean time of 3.5 minutes per “sign on”. The EMR was the most frequent applica-tion, followed by Medline and Internet accesses. Most popular software by applications were Scientific American Medicine and Pediatrics (the journal). Most frequent “time per” applications were E-Mail and Medline followed by a uniform pattern for the text and journal titles.
Conclusion: In its first 4 months, CLINT has had increasing acceptance and usage by members of the pediatric health care team. Housestaff were found to utilize CLINT’s resources the most. A review session repeated three months after the introduc-tion of CLINT was particularly effective in increasing its use among pediatric residents. Its main use has been in areas of patient care (EMR), Medline and Internet followed by texts. These usage patterns may change as more pediatric text titles become available on CD ROM. Individual’s comfort with computers re-main the most important element affecting utilization. (funded by Chedoke-McMaster Hospitals Foundation)
4
TELEPHONE DRIVEN, AUTOMATED PRESCRIPTION
RENEWAL SYSTEM (APRS) USING A TOUCH TONE
PHONE AND A FAX MACHINE.
Edward R. Christophersen, Ph.D., FAPA, Michael C. Luxem,
Ph.D. Dept. of Peds, Children’s Mercy Hospital, Kansas City, MO
Background: Patient requests for prescription renewals have evolved into a costly undertaking, particularly with controlled
substances. The phone must be answered (or phone mail
re-trieved), the necessary information written down, the patient’s
at Viet Nam:AAP Sponsored on September 1, 2020
www.aappublications.org/news
medical chart accessed, and the prescription form filled and signed by the physician. In our preliminary research, this process
(with an N of 80 actual renewals) took a mean of 5.5 minutes (S.D. I .7 minutes). Typically physicians do not charge for renewals,
although, in a busy office the time and expense involved is sig-nificant. A number of companies now offer computer programs that can generate electronic prescriptions. However, electronic prescriptions still require that someone answer the phone, that the office have the hardware (computer) and software (the computer
program for writing and transmitting the prescriptions), and have
trained staff members who can use the computer program
cor-rectly.
Methods: The APRS is telephone-driven by the patient or parent. Patients who have a touch-tone phone are given a small card to carry in their wallet or purse that lists the phone number to call and the answers to most of the questions that an Interactive Voice Response (DIR) computer (that is leased, on a time basis, by the
authors for the APRS) will ask them, using a recorded human voice. The patient dials an 800 number, presses touch-tone buttons to identify his physician, his own medical record, the prescription he wants to renew, whether he is benefiting from the prescription, and if he must be called by the physician’s office. The IVR com-puter, in turn, generates a completed prescription that is faxed to the prescribing physicians “fax box.” At any convenient time, the physician or nurse calls her fax box using a touch-tone phone, enters her “PIN” number, and all of her prescriptions are faxed to the office fax machine or an alternative fax machine (for physi-cians who practice out of more than one office or clinic) and the patient’s medication history is automatically updated. Once the prescription is signed by the physician, the prescription can be held for the patient, mailed (using a window envelope), or for-warded to the pharmacy. The physician, nurse, or clinic adminis-trator can also use a touch-tone phone to obtain a copy of any patient’s medication history at any time. Results: Preliminary test-ing (with one hundred trials) has indicated that the average num-ber of minutes spent on the phone, to retrieve all of the prescrip-tions since the last retrieval, is less than two minutes. Conclusion: It is now possible, without the cost of computer hardware or software, and with very little training time, to have patients gen-erate prescription renewals and upgrade their medication histo-ries, with a touch-tone phone. Because the prescription goes di-rectly to the prescribing physician’s office, there is no greater security risk than with a handwritten prescription. The authors have copyrighted the computer software for the APRS.
5
PEDINFO AT AGE 2: THE STATE OF THE PEDIATRIC
INTERNET.
S. Andrew Spooner, MD. University of Alabama at Birmingham,
Birmingham, AL
Background: Despite multiple Internet indexing services and search engines, it is difficult to locate pediatric information on the
World Wide Web (WWW). Indexes of medical information on the WWW exist, but pediatric information becomes obscured by gen-eral medical information in these indexes. The following study, based on the PEDINFO Internet index (httpi/www.uab.edu/ped-info), illustrates the need for pediatric-specific Internet indexes by (I) describing the content of the pediatric Internet through analy-sis of the PEDINFO database and (2) reporting on the usage patterns of the PEDINFO index.
Methods: (1) The PEDINFO Web site had been maintained as a set of WWW pages for 18 months without an underlying database to manage the growing number of Internet resources. For this study, the data from the Web pages were extracted and placed into a database. Categorization data added to the database
al-lowed analysis of the pediatric Internet by content. (2) To deter-mine usage patterns for the index, an on-line survey was imple-mented as an HTML form on the index for two weeks. The survey asked about the role of the person using the index (pediatrician, nurse, parent, etc.) and their purpose in using the index (browsing vs. searching for something specific). Descriptive statistics and
x
tests were used to describe the responses.Results: (I) There were a total of 587 distinct Internet resources from 429 different servers in the database, including the 55 mail-ing list servers that handle the 73 mailing lists. These resources included 38 departments of pediatrics, 27 professional organiza-tions, 24 pediatric practices, and 51 children’s hospitals. 135 re-sources from 18 pediatric medical subspecialties, 21 resources from 7 surgical subspecialties, and 80 resources 1 7 other areas of study were identified. Other types of resources dealt with diseases, educational resources on-line publications, parenting, and software. (2) 510 respondents submitted the on-line survey; 497 (97%) of these responded to the “purpose” question. 192 (39%) identified themselves as pediatricians. Most of these (84%) were practicing general pediatricians; 14% were pediatric subspecialists. 13 respondents (3% of total) were family or general practitioners. 52 (10%) were nurses-29 (56%) of these in advanced practice roles. 130 (26%) were parents. Parents were more likely than pediatricians to be looking for specific
infor-mation as opposed to browsing (85% vs. 56%, =31.2, p <
0.0001).
Conclusion: There is a broad variety of pediatric information on the Internet. While organizing this growing mass of infor-mation has been done as a “hobby” by several pediatricians, it may be time to consider a formal mechanism-including formal database techniques-to collaborate on a global pediatric Inter-net index. Pediatricians use the Internet both as a source of specific information and to browse for new information. Par-ents use the Internet to seek pediatric information, and pedia-tricians should consider their needs in creating on-line re-sources.
6
GUIDING PRIMARY CARE PROVIDERS TO ACCESS
MEDICAL GENETICS INFORMATION ELECTRONICALLY
AT THE TIME OF THE PATIENT ENCOUNTER.
V.K. Proud, MD, E.E. McColligan, MS, MPH. Laboratory of
Medical Genetics and Department of Health Services Administra-tion, University of Alabama at Birmingham.
Background: Information resources about genetics are being de-veloped and used daily by academic based clinicians. Unfortu-nately, the majority of primary care providers (PCPs) including ped iatricians and family physicians have no easy-to-use database of genetics information. While rising health care costs are placing new responsibilities on PCPs to control referrals for consultation, those same PCPs are being required to use increasingly complex medical genetics information and testing in daily patient care. Methods: Medical genetics information must be made available in a form that can be easily used at the point of patient care. We are developing an easy-to-use, PC-based software package and World
Wide Web (www) application called INFOGEN. The INFOGEN
Conclusions: It is necessary to consider the reason for
monitor-540 SUPPLEMENT
States). Results: Information contained in INFOGEN wifi aid PCPs to answer the following questions: (I) Does the patient’s problem have a genetic basis?; (2) Is updated information available about a known genetic disorder (ie, DNA testing)?; (3) Does the patient’s race or ethno-cultural background raise specific genetic questions that need to be addressed?; (4) How can the PCP contact the local genetics consultants?; (5) If a laboratory test is available, what are the steps which must be taken in order to submit a sample for standard testing?; and (6) How can the genetic support organiza-tions be contacted to provide patient information? Conclusion: After on-site training in the use of the computer software, the physicians and nurses participating will access information to answer brief, directed questions at the time of the patient encoun-ter. By using INFOGEN, they will improve their knowledge of medical genetics and understanding of the prevalence of genetic disorders in their practice, facilitate application of genetic labora-tory testing information to patient care, and be better informed in order to refer and use genetic services. Also, the experience with the on-site demonstrations and use of the PC-based software will allow computer-naive practitioners to gain familiarity with com-puter searching and information retrieval in order to be able to most effectively use the INFOGEN world wide web application that will access more detailed and comprehensive Internet re-sources.
7
TIME TREND MONITORING IN THE NEONATAL
INTENSIVE CARE UNIT: WHY DOESN’T IT MAKE A
DIFFERENCE.
Neil Mclntosh DSc(Med.), Andrew Lyon MB, FRCP, Peter
Bad-ger. Dept. of Child Life and Health, Univ. of Edinburgh, Scotland.
Background: In a three year study on neonatal computerized trend cot monitoring involving 600 intensive care neonates we were unable to detect improvement in outcome when the physi-ology was displayed.1
Aim: This paper explores possible reasons for the lack of im-proved outlook.
Results: Problems seen with examples:
I. Data overload-The more data which are displayed on a
screen, the more confusing the screen becomes, particularly to the new system user.
2. Data discrimination-Display of too much normal data to see the abnormal
-S up to 5 channels can be displayed on the screen concurrently. Vertical definition decreases with an increase in the number of channels.
0 time base-short events are not visible with data averaging.
3. Display of the wrong channels
-. pCO2 not displayed when a pneumothorax has occurred. . Display of respiration when the infant paralysed on a
venti-lator.
4. Scaling problems
-. vertical-eg. Blood pressure. Scaling may include artifact.
. wrong time base-apnea not visible on I minute averages.
ing:
. reassurance that a parameter is normal
. early warning-limit alarm or trend
. a legal record
Depending on which of these is most important then it may be possible to design:. I. better visual display-eg delta temp.
2. better channel selection-PO2 is poor, FiO2 is better, p02/ FiO2 is best.
3. automatic scaling-use of the best scale for range of values observed: this would be even better if artifact was automat-ically discarded.
4. intelligence-when FiO2 increases with a pneumothorax, you
get increase also in CO2. ie channel combinations considered by algorithm.
* reference-Mcintosh N, Cunningham 5, Elton R. A
random-ized trial of computerized cot monitoring. Pod Res 1994; 36: 28A (abstract 155)
8
PATIENT SATISFACTION WITH PAPER-BASED VERSUS
PERSONAL DIGITAL ASSISTANT-BASED SURVEY
COMPLETION
Kevin B. Johnson, MD, MS, FAAP, Michele D. Wilson, MD,
FAAP, Stephanie Arnold, Alain Joffe, MD, FAAP
OBJECTIVES: The purpose of this study was to assess patient satisfaction among adolescent females using personal digital as-sistant (PDA)-based compared to paper-based interviewing tech-niques.
METHODS: Adolescent females were asked to complete a ques-tionnaire as part of a pregnancy prevention project. Using consec-utive enrollment, the first 10 patients completed the questionnaire using the paper instrument; the subsequent 10 patients used the PDA. After completing the survey, the respondents assessed the ease of completion for the instrument they used.
RESULTS: Survey completion required approximately 30
ruin-utes by paper as compared to 20 minutes with the PDA. No
subject considered the PDA to be “irritating” or “boring” while 5 subjects considered the paper-based survey to be “irritating” or “boring” (P < 0.05; Fisher’s Exact test). Six subjects using the PDA described it as “easy” or “fun” compared to only 2 similar ratings for the paper-based survey. Both formats were considered to have high readability. When asked whether they thought other teenag-ers would like answering questions using a similar instrument, 7/10 PDA users said other teenagers would “love it” or “think it was pretty nice” while 7/10 paper survey users said others would “not like it.” When asked to describe how they would like using the assigned method if they were not feeling well that day, 9/10 PDA users thought that it would be a “good way” or “the best way I could imagine”, versus only 2/10 paper survey users (P <
0.01; Fisher’s Exact test). There was no difference in perceived level of privacy offered by either method.
CONCLUSION: These data suggest that the use of a PDA to complete a questionnaire is a desirable method for adolescents.
