International Journal of Medical Informatics

Evaluating large scale health information systems (HIS) such as hospital systems can be difficult. This article discusses the reasons we need to evaluate these systems and a range of appropriate methods to carry out evaluations. It is written in non-technical language to assist health policy makers and others commissioning or implementing such systems, with references and a web site containing information for those wishing more detail (http://www.ucl.ac.uk/kmc/evaluation/index.html). A variety of questions relevant to HIS and qualitative and quantitative methods ranging from simple before-after to controlled before-after and fully randomised designs, are discussed. A running example--evaluating the impact of an order communications system on lab requests--is used to illustrate the potential problems, and how they can be resolved. The main types of biases affecting impact studies and methods to reduce them are described. The article then discusses some trade-offs between the low cost, easily conducted before-after study with its unreliable results versus the more complex, expensive but much more rigorous randomised trial. As would be expected, the correct methods to evaluate depend not on what technology is being evaluated--whether an information system or a drug--but on the questions the study is designed to answer, and how reliable the answers must be. Only those commissioning an evaluation study can decide these.

This article presents initial results from a European multi-centre study to determine the effectiveness and feasibility of an online self-help treatment support program for Bulimia Nervosa (BN). The online program is based on Cognitive Behavioral Therapy (CBT) and consists of seven steps that patients work through progressively. An overall sample of 141 women suffering from BN used the program over a 6-month period. Patients were supported by three face-to-face evaluation interviews with a therapist, and a weekly e-mail contact. Data on general psychopathology and specific eating disorder symptoms were also collected at the evaluation interviews. Initial results from the Swiss sample (N=41) showed significant improvement of overall psychological health (p<.001) as measured by the Symptom Checklist (SCL-90R), and for all dimensions of the Eating Disorder Inventory (EDI-2). An online Self-Help program for BN can be used effectively to reduce eating disorder symptoms in Bulimic patients and user feedback showed that this approach contributed to increase patient involvement and service availability. Additional data from the other centers will further inform the efficacy and impact of this approach.

To analyze and evaluate the newly issued Electronic Health Record (EHR) Architecture and Data Standard of China (Chinese EHR Standard) and identify areas of improvement for future revisions. We compared the Chinese EHR Standard with the standard of the American Society for Testing and Materials Standard Practice for Content and Structure of Electronic Health Records in the United States (ASTM E 1384 Standard). The comparison comprised two steps: (1) comparing the conformance of the two standards to the international standard: Health Informatics-Requirements for an Electronic Health Record Architecture (ISO/TS 18308), and showing how the architectures of the two standards satisfy or deviate from the ISO requirements and (2) comparing the detailed data structures between the two standards. Of the 124 requirement items in ISO/TS 18308, the Chinese EHR Standard and the ASTM E 1384 Standard conformed to 77 (62.1%) and 111 (89.5%), respectively. The Chinese EHR Standard conformed to 34 of 50 Structure requirements (68.0%), 22 of 24 Process requirements (91.7%), and 21 of 50 Other requirements (42.0%). The ASTM E 1384 Standard conformed to 49 of 50 Structure requirements (98.0%), 23 of 24 Process requirements (95.8%), and 39 of 40 Other requirements (78.0%). Further development of the Chinese EHR Standard should focus on supporting privacy and security mechanism, diverse data types, more generic and extensible lower level data structures, and relational attributes for data elements.

To assess progress made in hospital information systems (HIS) since 1979, when the forerunner of the International Medical Informatics Association Working Group on HIS first met. A review of the recommendations made in 1979 identified core concerns, which were analyzed in light of the state of the art in 2002. Despite significant changes over the years, the underlying concerns identified in 1979 are still valid today. In 2002 as in 1979, HIS must be integrated into the hospital's organizational structure; financial and economic benefits depend upon using technology as an enabler of improved clinical outcomes; and education and training remain critical to the successful use of technology solutions. The tools available for addressing these concerns have changed enormously. Where there were dumb terminals, there are the World Wide Web and handheld devices. As a result, we are raising our expectations and changing the terms of our discussions. Today the focus is shifting to patient safety, decision support, and evidence-based practice; the concerns voiced in 1979 have become medical informatics cornerstones. New tools and new approaches now available can improve the quality of care. Using them appropriately requires careful planning and education for patients as well as healthcare professionals.

To obtain an overview of study designs and study methods used in research evaluating IT in health care, to present a list of quality criteria by which all kinds of reported evaluation studies on IT systems in health care can be assessed, and to assess the quality of reported evaluation studies on IT in health care and its development over time (1982-2005). A generic 10-item list of quality indicators was developed based on existing literature on quality of medical and medical informatics publications. It is applicable to all kind of IT evaluation papers and not restricted to randomized controlled trials. One hundred and twenty explanatory papers evaluating the effects of an IT system in health care published between 1982 and 2005 were randomly selected from PubMed, the study designs and study methods were extracted, and the quality indicators were used to assess the quality of each paper by two independent raters. The inter-rater variability of scoring the 10 quality indicators as assessed by a pre-test with nine papers was good (K=0.87). There was a trend towards more multi-centre studies and authors coming more frequently from various departments. About 70% of the studies used a design other than a randomized controlled trial (RCT). Forty percent of the studies combined at least two different data acquisition methods. The quality of IT evaluation papers, as defined by the quality indicators, was only slightly improving in time (Spearman correlation coefficient [rs]=0.19). The quality of RCTs publications was significantly higher than the quality of non-RCT studies (p<0.001). The continuous and dominant number of non-RCT studies reflects the various approaches applicable to evaluate IT systems in health care. Despite the increasing discussion on evidence-based health informatics, the quality of published evaluation studies on IT interventions in health care is still insufficient in some aspects. Journal editors and referees should take care that reports of evaluation on IT systems contain all aspects needed for a sufficient understanding and reproducibility of a paper. Publication guidelines should be developed to support more complete and better publications of IT evaluation papers.

The HELP hospital information system has been operational at LDS Hospital since 1967. The system initially supported a heart catheterization laboratory and a post open heart Intensive Care Unit. Since the initial installation the system has been expanded to become an integrated hospital information system providing services with sophisticated clinical decision-support capabilities to a wide variety of clinical areas such as laboratory, nurse charting, radiology, pharmacy, etc. The HELP system is currently operational in multiple hospitals of LDS Hospital's parent health care enterprise--Intermountain Health Care (IHC). The HELP system has also been integrated into the daily operations of several other hospitals in addition to those at IHC. Evaluations of the system have shown: (1) it to be widely accepted by clinical staff; (2) computerized clinical decision-support is feasible; (3) the system provides improvements in patient care; and (4) the system has aided in providing more cost-effective patient care. Plans for making the transition from the 'function rich' HELP system to more modern hardware and software platforms are also discussed.

Web 2.0 internet tools and methods have attracted considerable attention as a means to improve health care delivery. Despite evidence demonstrating their use by medical professionals, there is no detailed research describing how Web 2.0 influences physicians' daily clinical practice. Hence this study examines Web 2.0 use by 35 junior physicians in clinical settings to further understand their impact on medical practice. Diaries and interviews encompassing 177 days of internet use or 444 search incidents, analyzed via thematic analysis. Results indicate that 53% of internet visits employed user-generated or Web 2.0 content, with Google and Wikipedia used by 80% and 70% of physicians, respectively. Despite awareness of information credibility risks with Web 2.0 content, it has a role in information seeking for both clinical decisions and medical education. This is enabled by the ability to cross check information and the diverse needs for background and non-verified information. Web 2.0 use represents a profound departure from previous learning and decision processes which were normally controlled by senior medical staff or medical schools. There is widespread concern with the risk of poor quality information with Web 2.0 use, and the manner in which physicians are using it suggest effective use derives from the mitigating actions by the individual physician. Three alternative policy options are identified to manage this risk and improve efficiency in Web 2.0's use.

This paper provides a five-year (2002-2007) comparative segmentation analysis of how the Internet and dedicated health networks are used by European general practitioners (GPs) and the extent to which external factors affect their use of various eHealth services. Two cross-national sets of survey data collected in 2002 (n=3512) and 2007 (n=3948) have been analyzed. These databases provide information on physicians' eHealth uses in EU-15 countries, including sociodemographic indicators such as country, age, sex, location, and size of the medical practice. A total of 3512 and 3948 physicians, respectively, participated in the 2002 and 2007 studies. The percentage of GPs accessing the Internet or a dedicated health network increased from 64.5% in 2002 to 77.1% in 2007. Only these physicians were included in the latent class cluster analyses performed on both datasets, yielding three segments of eHealth users plus a group of non-Internet users. Thus, the following four final segments were identified in the years 2002 and 2007: 'Information Searchers/Average Users', 'Advanced Users/Adv. Users (ePrescribers)', 'Laggards', and 'Non-Internet Users'. Contingency table analyses relating external indicators to physicians' usage patterns of eHealth services confirmed strong country differences, low to moderate age influences reflecting a cohort effect, and moderate effects of practice size, both in 2002 and 2007. Conversely, very weak influences were observed for physicians' sex and location of the medical practice. A positive evolution is clearly observable in European primary care physicians' use of eHealth, mainly with regard to online medical information searches, use of electronic health care records, and (to a lesser extent) electronic transfers of patient data. The international comparative profiling of European GPs' eHealth usage patterns contributes to more efficient and continually adapted promotion strategies, aimed at fostering the diffusion of eHealth applications among medical professionals of the analyzed EU-15 countries.

There is a lack of literature about health information systems (HIS) in "developing" countries, including Vietnam. However, computerization and network development are proceeding in these places, although not in a systematic, transparent way. This is a preliminary overview of HIS's and healthcare communications in Vietnam's four-tiered public healthcare system. It is to indicate the direction that nation might take in order to establish a modern, standards-compliant, national HIS. We conducted site visits and interviews in Hanoi and nearby provinces. Additional information was derived from publications of the Vietnamese government and the United Nations. Many of the top-level "central" hospitals have HIS's, although their quality and daily usage varies. Fewer provincial hospitals have networks; district hospitals have a few stand-alone computers, and commune health centers have no computers. Patients often go directly to higher-level providers, due to a widely held perception of better care at such sites. Communications among healthcare units are largely on paper, consisting mostly of administrative matters and some hand-written patient referrals. Telephones are used for discussions of specific matters. Internet connections are almost all dial-up and often belong to individual staff members rather than the healthcare units. Lower-level units derive much of their general medical information from television and newspapers. However, there is considerable interest in computerization among healthcare workers at all levels. Familiarization with computerized communications, i.e., training and hardware at all healthcare levels, must be the first step towards a modern healthcare communications network in Vietnam. The skills to do this already exist. The aim of such a network must be to raise the level of information and quality of care at the lower levels. Adherence to international standards, such as HL7, from the beginning would enable the country to bypass many years of haphazard development.

Held on 21st to 23rd November 2009 in Hiroshima, the SiHIS working conference aimed at finding solutions to approach to an idealistic society where (1) the individual can trust information with full understanding and responsibility, (2) the individual can allow the use of information backed by sound legitimated environment, (3) information can play its role for better healthcare and the improvement of medicine. The purpose of this paper is to propose recommendations from this working conference.

The paper, entitled 'Health care in the information society-a prognosis for the year 2013' is in this commentary compared with previous relevant documents. In the paper quantitative prognoses are presented for each of 30 theses. Some developments such as the influence of genomic medicine on health care were not covered by the theses. ICT measures as suggested in the paper are quite acceptable but the paper does not mention side effects of ICT on health care and is therefore a bit unbalanced. As a reference, the Japanese grand design for information-oriented health care is also introduced.

A prognosis of how the information society in health care will look like in 2013 must start from the current state of affairs at the given locality regarding healthcare management by public authorities including legislative, ICT technological levels and accessibility of professional knowledge in individual fields of medicine. It is presumed that after 10 years the influence of this 'starting point' will still persist and knowledge of the current state of affairs will be needed to positively but also negatively differentiates the prognosis [Health Care in the Information Society: A Prognosis for the Year 2013, in this issue] for individual localities, e.g. Germany versus neighbouring the Czech Republic. The present article focuses on aims of Czech health care and the measures that are taken in Czech health care that are carried out and which have been already initiated. Their significance towards the future prognosis according to [Health Care in the Information Society: A Prognosis for the Year 2013, in this issue] is clear. The first measure is legalisation of conditions, which allow health care administration only be carried out with electronic forms and the protection of these sensitive personal data when they are placed in a centralised data depository where they are prepared for physicians who use them while providing health care in health institutions. In the Czech Republic an information system is developed called Internet Access to Health Patient Information (IHPI). The second measure is creating a unified central system of health information together with methodologies for data collection, data standards and protocols. In the Czech Republic there is the National Health Information System (NHIS) governed by the Institute for Health Information and Statistics (IHIS CR). The NHIS enables care providers to get information about the health state of citizens, about health institutions, about their activities and economics, it enables to regulate the provision of health care, to define conceptions of state health politics and to administrate public health. The third measure is legalisation of possibilities to establish centralised health care registers that are designated for recording and following of patients with chosen socially serious diseases. These registers help with diagnosis and therapy and reveal consequences of diseases for the patients. It helps to evaluate accessibility and quality of provided health care in the country. An important goal of the use of health care registers and information systems is for educational purposes and as causal expert systems for physicians. The National Health Registers have been introduced to the whole of the Czech Republic; some of them are accessible on-line in a countrywide data network. The last part of the paper focuses on research and education for developing the information society in Czech health care and on co-operation with EU countries in selected projects and initiatives.

Our society is increasingly influenced by modern information and communication technology (ICT). Health care has profited greatly by this development. How could health care provision look in the near future, in 10 years, or more precisely, in the year 2013? What measures must be undertaken by political and self-governing health institutions, and by medical informatics research, to ensure an efficient, medically advanced and yet affordable future health care system? Three factors will greatly influence the further development of information processing in health care within the near future: the development of the population, medical advances, and advances in informatics. These factors have motivated us to set up 30 theses for health care provision in the year 2013. The theses cover areas of health care, such as its people, its information systems, and its ICT tools. Three major goals requiring achievement have been identified: patient-centered recording and use of medical data for cooperative care, process-integrated decision support through current medical knowledge, comprehensive use of patient data for research and health care reporting. In consequence, political institutions should provide a framework for networked, patient-centered health care. They are called on to regulate the storage and exchange of health care data and of appropriate information system architectures. Finally, the health care institutions themselves must emphasize professional information management more strongly. Relevant research topics in medical informatics are: comprehensive electronic patient records, modern health information system architectures, architectures for medical knowledge centers, specific data processing methods ('medical data mining'), and multi-functional, mobile ICT tools.

New knowledge from biotechnology and new capabilities provided by the evolving global information infrastructure are already transforming health care. Three clusters of technologies hold particular promise: grid computing, intimate computing, and micro laboratory computing. The confluence of these technologies will change clinical laboratory equipment into portable devices, easing the administrative details involved in delivering care and ushering in a new age of monitoring clinical states. Two vignettes, an office visit and a clinical trial, are offered as prognosis for clinical care in 2013. New capabilities hold the power to transform health care, making it truly patient centered as the Institute of Medicine (IOM) has urged.

This commentary of Haux' prognosis of the state of affairs in health care and information technology in the year 2013 argues the importance of standing up against the many high-tech, utopian dreams that are often associated with ICT in health care. Discussing many of the themes that Haux brings up, three issues are particularly focused upon: the importance of 'patient-centered' care, the changing position of the professional in current health care, and the nature of health care information. In all these issues, cliches threaten to hide several real and possibly painful issues, which, if unaddressed, will hamper any real progress. In all these issues, moreover, medical informatics plays an important role, and is a core actor in the future shaping of our health care systems. This responsibility should not be taken lightly.

This paper aims at further expanding the vision of future health care delivery systems presented by Haux et al. (2002). Starting from the observation that information and communication technology (ICT) is deeply transforming the shape of organizations as expected, we argue that the coordination of work activities is a fundamental need for any organization. This is even more important for health care organizations since there is an increasing pressure to increase quality of care they deliver without further increasing its costs. However ICT by itself will not cause the desired changes without rethining the way of managing best practice biomedical knowledge and care delivery processes. Thus the paper focuses on the need of developing intense research efforts in the fields of knowledge management and workflow modelling, which have been identified as fundamental to provide suitable solutions to the problems of designing and building innovative health care information systems. Moreover, the paper discusses the role of mobile communication systems. Moreover, the paper discusses the role of mobile communication and speech understanding technologies to support a satisfactory user-system interaction in daily work.

Internet-based, personal health records have the potential to profoundly influence the delivery of health care in the 21st Century, by changing the loci and ownership of the record from one that is distributed among the various health care providers a patient has seen in his lifetime, to one with a single source that is accessible from anywhere in the world and under the shared ownership and control of the patient and his provider(s). Internet-based personal health records (PHRs) include any internet-accessible application that enables a patient (or his guardian, the 'mom') to review, annotate, create or maintain a record of any aspect(s) of his health condition, medication, medical problems, allergies, vaccination history, visit history or communications with his healthcare providers. The current state-of-the-art for personal health records is best characterized as 'beta releases'. As the field matures and gains more experience, these applications will improve significantly in ease of use and functionality.

This paper introduces the topic of this special issue: challenges for medical informatics in the 21st century. This paper discusses the nature of medical informatics. Some descriptions and definitions of medical informatics are reviewed. Then the research aspects of medical informatics are discussed. It is argued that the more mundane aspects of medical informatics like system development and implementation are important and need further consideration, especially concerning social aspects and correctness.

This manuscript describes the value of and proposal for a high-level architectural framework for a Public Health Grid (PHGrid), which the authors feel has the capability to afford the public health community a robust technology infrastructure for secure and timely data, information, and knowledge exchange, not only within the public health domain, but between public health and the overall health care system. The CDC facilitated multiple Proof-of-Concept (PoC) projects, leveraging an open-source-based software development methodology, to test four hypotheses with regard to this high-level framework. The outcomes of the four PoCs in combination with the use of the Federal Enterprise Architecture Framework (FEAF) and the newly emerging Federal Segment Architecture Methodology (FSAM) was used to develop and refine a high-level architectural framework for a Public Health Grid infrastructure. The authors were successful in documenting a robust high-level architectural framework for a PHGrid. The documentation generated provided a level of granularity needed to validate the proposal, and included examples of both information standards and services to be implemented. Both the results of the PoCs as well as feedback from selected public health partners were used to develop the granular documentation. A robust high-level cohesive architectural framework for a Public Health Grid (PHGrid) has been successfully articulated, with its feasibility demonstrated via multiple PoCs. In order to successfully implement this framework for a Public Health Grid, the authors recommend moving forward with a three-pronged approach focusing on interoperability and standards, streamlining the PHGrid infrastructure, and developing robust and high-impact public health services.

The present widespread tomographic techniques based on computed tomography (CT), magnetic resonance imaging (MRI) and automatic 2D and 3D reconstructions also involve numerous new points of view for planning surgical techniques in orthopaedy. These require efficient pre- and post-processing methods. By pre-processing and post-processing is meant both the generation of a finite element mesh that numerically models human joints and the visualization of the results obtained as required by the surgeon. Since the numerical reconstructions of human joints are based on the finite element approximation of contact problems assuming linear elasticity, the main goal of pre-processing is to generate triangular (2D) and tetrahedral (3D) meshes of objects with a 'reasonable' boundary-human joints. In our paper we restrict ourselves, for the sake of simplicity, to polygonal (resp. polyhedral) objects. The idea of preprocessing is based on the modified method of Delaunay Mangulalia and on the so-called relaxation technique. After the generation of the finite element mesh and after numerical simulation of surgical problems of orthopaedy, the results obtained as stress-strain fields, temperature, etc. may be visualized in a graphical form on the computer screen as well as on other media.

The development of problem-oriented conceptual models for electronic patient record (EPR) systems can improve data communication between health professionals. But little has been done so far to investigate to what extent it is possible to implement such models in operational EPR systems. In this paper, we measure the conformance between a conceptual model and the various ways it is implemented within general practitioners' (GPs') electronic patient records. We started from a simple problem-oriented conceptual model and we defined an original discriminating method to assess its implementation. This method is scenario-based (dummy patient), functional, and relative (comparison between software systems). Each implementation is assessed by two evaluators and the final result is a "success/failure" score. The assessment was performed within the scope of the official Belgian accreditation procedure for GPs' electronic patient records, which is voluntary, publicly funded, and based on a dynamic quality improvement paradigm. Almost all Belgian GPs' software systems (17) were assessed. The robustness of our results was assessed through a sensitivity analysis. We found that 65% (11/17) of the software systems currently used succeeded in implementing the problem-oriented conceptual model with a high confidence level (error rate<10%). The results were widely accepted by the software developers. A problem-oriented conceptual model can be successfully implemented in many operational EPR systems. The quality of the implementation can be assessed. Our results could be used at the international level to improve semantic interoperability between patient information systems, for instance in relation to broader conceptual models such as the European CONTsys pre-norm.

Self-monitoring of blood glucose has become routine practice in the management of diabetes mellitus. When all the data is complete, however, the amount of information to be taken into account when making therapeutic decisions becomes overwhelming not only for the patient but for the healthcare provider. Computers excel at processing large amounts of information quickly and impassively, which makes them potentially helpful for collating and communicating the data in a manner that facilitates decision-making by patient and healthcare provider. This should in turn improve control and help prevent acute and chronic complications. Using the Vista 350 telephone, we have developed a system that enables patients with diabetes to record home monitoring data to a central database and receive feedback summaries. A small trial was conducted to determine if the Vista 350 telephone is an acceptable and feasible method to communicate the results of home monitoring of diabetes mellitus to a central database and receive feedback summaries. A total of 35 volunteers with insulin-requiring diabetes mellitus in the London area were randomly allocated to either use the Vista 350 phone for 6 months, or to a control group that continued to use traditional methods for recording home monitoring data. 33 of the 35 patients enrolled completed the trial. All 16 patients who began using the phone continued to do so for 6 months confirming the feasibility of the system. Questionnaires completed at 3 and 6 months confirmed the Vista 350 telephone system to be acceptable to the subjects. The results will enable some minor modifications to be made to the telephone system before a larger definitive trial, designed to determine the effect on diabetes control, is conducted later this year.

In the 1970s, the Leiden University Hospital developed a computerized hospital information system (HIS), which was further developed to manage access control. Although password protection has been the mainstay of access control in the hospital, new trends in data protection are emerging. Instead of password, smart cards are being developed. The use of smart cards will enable new facilities for use of encryption without bothering the user with complicated details. In order to overcome complicated situation due to various systems in the network, a secure single log-on facility is also being considered as an alternative.

Objective: Advanced life support (ALS) knowledge and skills decrease in as little as three months, but only a few ALS providers actually attend retraining courses. We assess the effectiveness of a 3D serious game as a new tool for frequent ALS retraining. Methods: We developed a 3D serious game for scenario-based ALS retraining. The serious game, called EMSAVE, was designed to promote self-correction while playing. We organized a retraining course in which 40 ALS providers played two cardiac arrest scenarios with EMSAVE and took a test with 38 multiple-choice questions before and after playing. We administered the same test again 3 months later to evaluate retention. Participants also rated EMSAVE and the overall retraining experience. Results: After using EMSAVE, the number of correct answers per participant increased by 4.8 (95%CI +3.4, +6.2, p<0.001) and all but one participant improved. After 3 months, despite an expected decrease in ALS knowledge and skills (-1.9 correct answers, 95%CI -0.6, -3.3, p<0.01), there was a significant retention benefit (+2.9 correct answers per participant, 95%CI +1.5, +4.2, p<0.001). Moreover, all but one participant regarded EMSAVE as a valuable tool to refresh ALS knowledge and skills, and 85% of participants were also willing to devote 1h/month to retrain with the serious game. Conclusions: A 3D serious game for scenario-based retraining proved effective to retrain in ALS and supported retention of acquired knowledge and skills at 3 months. EMSAVE also positively engaged and motivated participants.

Our paper describes an integrated methodology addressing the development of an Internet service for medical professionals, medical students and generally, people interested in medicine. The service (currently developed in the framework of IAEVA, a Telematics Application Programme project of the European Union), incorporates a mechanism for retrieving from a relational database (reference library) 3D volumetric models of human organs reconstructed from computer tomography (CT) and/or magnetic resonance imaging (MRI). Retrieval is implemented in a way transparent to the actual physical location of the database. Prospective users are provided with a Solid Object Viewer that offers them manipulation (rotation, zooming, dissection etc.) of 3D volumetric models. The service constitutes an excellent foundation of understanding for medical professionals/students and a mechanism for broad and rapid dissemination of information related to particular pathological conditions; although pathological conditions of the knee and skin are supported currently, our methodology allows easy service extension into other human organs ultimately covering the entire human body. The service accepts most Internet browsers and supports MS-Windows 32 platforms; no graphics accelerators or any specialised hardware are necessary, thereby allowing service availability to the widest possible audience. Nevertheless, the service operates in near real-time not only over high speed expensive network lines but also over low/medium network connections.

The aim of this study was to evaluate the effect of introducing the Dental 3D Multimedia (D3DM) System on dentist-patient interactions. An initial version of the D3DM developed in a series of researches was applied to the current study. A longitudinal pre-post study was setup: volunteer patients answered questionnaires at three differing intervals during the course of the study: before the introduction of the D3DM during the first visit, after the introduction of the D3DM during the first visit, and after the introduction of the D3DM during the second visit. The questionnaires related to patient satisfaction and covered three main areas of interests: (1) satisfaction with visit components, (2) comprehension about dental issues, and (3) perceptions with regard to dental office computing. Compared with baseline, patient overall satisfaction increased significantly both immediately after the introduction of the D3DM and at the second visit. Patient's satisfaction with dentist's familiarity with them, and satisfaction with dental issues generally increased. On measures of psychological communication and available time, patients generally reported that no changes occurred during visits. A majority of participants reported that they preferred the D3DM more than traditional dentist-patient communication patterns. There were no significant changes in patient perceptions of the computer use over time. the D3DM appeared to have positive effects on dentist-patient communications, improving the mutual understanding between them. There were no significant negative effects directly generated from the computer intervention. Further research is needed to update the current D3DM and investigate how the system might be best implemented in the dental office environment.

Virtual Reality Modelling Language (VRML) is the start of a new era for medicine and the World Wide Web (WWW). Scientists can use VRML across the Internet to explore new three-dimensional (3D) worlds, share concepts and collaborate together in a virtual environment. VRML enables the generation of virtual environments through the use of geometric, spatial and colour data structures to represent 3D objects and scenes. In medicine, researchers often want to interact with scientific data, which in several instances may also be dynamic (e.g. MRI data). This data is often very large and is difficult to visualise. A 3D graphical representation can make the information contained in such large data sets more understandable and easier to interpret. Fast networks and satellites can reliably transfer large data sets from computer to computer. This has led to the adoption of remote tale-working in many applications including medical applications. Radiology experts, for example, can view and inspect in near real-time a 3D data set acquired from a patient who is in another part of the world. Such technology is destined to improve the quality of life for many people. This paper introduces VRML (including some technical details) and discusses the advantages of VRML in application developing.

The aim of our study was to obtain a 3D model of the prostate from the ultrasound images and to represent it and calculate its volume. The establishing of prostate volume represents a necessary stage in choosing the method of solving prostate adenoma. The evaluation of the prostate volume can be done by transabdominal or endorectal echography. If the second method is not available it is necessary to use the echographic estimation of the volume of the prostate adenoma by suprapubian examination. This method lacks precision. In order to have a more accurate calculation of the prostate's volume than the ellipsoid approximation given by the echographic equipment, we designed a software tool for handling and management of digital images. The primary information is composed of two 2D digital images obtained by digitising the frames acquired from an 3.5 MHz ultrasound equipment for two incidences: sagittal and transversal. The bitmaps were filtered to reduce the noise and a contour detection algorithm was used. Further, the new 2D detected contours were processed with the help of an interactive image editor toward a 3D reconstruction of the prostate. The examiner can perform rotations and translations on the 2D projections and can adjust the angle between them. The resulting object (the 3D model of the prostate) was adjusted accordingly and its volume was displayed. The software was implemented on a PC system and was used in the Urology Clinic for several cases. It has been shown that, compared with the value provided by the approximation of the echographic equipment, a more accurate value of the volume of the prostate was obtained.

In this manuscript we report an evaluation of the reliability of clinical research rules creation by multiple clinicians using the Health Archetype Language (HAL-42) and user interface. HAL-42 is a language which allows real time epidemiological inquiry using automatically derived clinical encodings with any health Ontology. This evaluation used SNOMED CT as the underlying Ontology. The inquiries were performed on a population of 17,731 patients whose 50,000 clinical records have all been fully encoded in SNOMED CT. Four subject matter experts (SMEs) were asked independently to encode and run 10 rules/studies. The inter-rater agreement was 74.8% (p=0.6526) with a Kappa statistic of 0.49217 (p=0.5722). The ten rules were divided into three easy rules, four moderate and three complex rules. There was no significant difference in the SME's agreement when representing easy and complex rules (p=0.6243). We conclude that although the usability of the HAL-42 language is usable enough to achieve reasonable inter-rater reliability, some training will be necessary to reach high levels of reliability for ad hoc queries. We also conclude that SMEs are just as competent to perform complex queries as easy queries of ontologically indexed clinical data.

The development of 4D CT imaging has introduced the possibility of measuring breathing motion of tumors and inner organs. Conformal thoracic radiation therapy relies on a quantitative understanding of the position of lungs, lung tumors, and other organs during radiation delivery. Using 4D CT data sets, medical image computing and visualization methods were developed to visualize different aspects of lung and lung tumor mobility during the breathing cycle and to extract quantitative motion parameters. A non-linear registration method was applied to estimate the three-dimensional motion field and to compute 3D point trajectories. Specific visualization techniques were used to display the resulting motion field, the tumor's appearance probabilities during a breathing cycle as well as the volume covered by the moving tumor. Furthermore, trajectories of the tumor center-of-mass and organ specific landmarks were computed for the quantitative analysis of tumor and organ motion. The analysis of 4D data sets of seven patients showed that tumor mobility differs significantly between the patients depending on the individual breathing pattern and tumor location.

To automatically evaluate the quality of health information on the Internet, we presents a method for detecting indicators for quality of health information. An automatic indicator detection tool (AIDT) was developed in the following steps: (1) 18 initial technical criteria were chosen; (2) multiple measurable indicators were defined for each criterion; (3) these measurable indicators on the Web pages were automatically detected by a computer program; (4) the detectable indicators were selected for each criterion based on detection accuracy and occurrence frequency, and detecting criteria on Web pages; (5) AIDT was developed based on the detectable indicators and criteria. The efficiency of detection tool was measured by recall and precision of detecting criteria. The performance of AIDT was tested using three data sets. AIDT with validated detectable indicators can reach 93% recall and 98% precision on these data sets. AIDT can automatically and correctly detect measurable criteria on Web pages. Automatic detecting indictors for quality of health information is feasible and effective. Using an automatic detecting tool is a promising method for identifying quality criteria of health information, and eventually it can be used to develop instruments for evaluating the quality of health Websites.

This study evaluated the post-implementation impact of a nursing information system and identified issues related to the technology adoption process. Given the high level of investment necessary to implement information systems, evaluation has become vital to ensure successful adoption and use. Improved understanding of implementation difficulties/barriers and factors leading to them can serve as a platform for the development of strategies and education programs for users. The study design was a two-stage data comparison analysis of a nursing information system focusing on computerized nursing care plan use. Data were collected from nurses by questionnaire during the first month (December 2004) and 1 year after system installation (December 2005). While nurses gave the information technology a higher evaluation score at the second stage than at the early stage, the overall ratings were slightly negative at both stages. Age and pressure to use the system were critical factors at both stages, whereas computer skills and perceived time using the system were vital at the beginning stage of implementation. Issues of concern at both stages were system functionality, efficiency, usability, and user support. Implementation of an information system requires consideration of issues involving hardware and software, staff training, organizational policy, and workflow changes.

Intro: The proper use of ICT services can support seniors in living independently longer. While such services are starting to emerge, current proprietary solutions are often expensive, covering only isolated parts of seniors' needs, and lack support for sharing information between services and between users. For developers, the challenge is that it is complex and time consuming to develop high quality, interoperable services, and new techniques are needed to simplify the development and reduce the development costs. This paper provides the complete view of the experiences gained in the MPOWER project with respect to using model-driven development (MDD) techniques for Service Oriented Architecture (SOA) system development in the Ambient Assisted Living (AAL) domain. Method: To address this challenge, the approach of the European research project MPOWER (2006-2009) was to investigate and record the user needs, define a set of reusable software services based on these needs, and then implement pilot systems using these services. Further, a model-driven toolchain covering key development phases was developed to support software developers through this process. Evaluations were conducted both on the technical artefacts (methodology and tools), and on end user experience from using the pilot systems in trial sites. Results: The outcome of the work on the user needs is a knowledge base recorded as a Unified Modeling Language (UML) model. This comprehensive model describes actors, use cases, and features derived from these. The model further includes the design of a set of software services, including full trace information back to the features and use cases motivating their design. Based on the model, the services were implemented for use in Service Oriented Architecture (SOA) systems, and are publicly available as open source software. The services were successfully used in the realization of two pilot applications. There is therefore a direct and traceable link from the user needs of the elderly, through the service design knowledge base, to the service and pilot implementations. The evaluation of the SOA approach on the developers in the project revealed that SOA is useful with respect to job performance and quality. Furthermore, they think SOA is easy to use and support development of AAL applications. An important finding is that the developers clearly report that they intend to use SOA in the future, but not for all type of projects. With respect to using model-driven development in web services design and implementation, the developers reported that it was useful. However, it is important that the code generated from the models is correct if the full potential of MDD should be achieved. The pilots and their evaluation in the trial sites showed that the services of the platform are sufficient to create suitable systems for end users in the domain. Conclusions: A SOA platform with a set of reusable domain services is a suitable foundation for more rapid development and tailoring of assisted living systems covering reoccurring needs among elderly users. It is feasible to realize a tool-chain for model-driven development of SOA applications in the AAL domain, and such a tool-chain can be accepted and found useful by software developers.

Education is essentially giving people new skills and qualifications to fulfil certain tasks. In planning and managing educational programmes it is crucial to know what skills and what qualifications are needed to carry out the tasks in question, not to mention the importance of knowing what tasks are relevant to carry out. The programme in health informatics at Aalborg University produces health informatics professionals. The students are developing skills in solving informatics problems in health care organisations. The programme has been running for 3 years now and to maintain the perception of the aim for the programme a number of activities have been launched. In the following, the programme will be presented, the activities to obtain information on how to keep the programme targeted and updated will be described and the changes that are going to be introduced will be outlined.

The present study evaluated whether an intervention using a short message service (SMS) by personal cellular phone and Internet would reduce cardiovascular risk factors in post-menopausal women with abdominal obesity over 12 weeks. This is a quasi-experimental design with pre and post tests. Participants were recruited from the gynecology outpatient and family medicine departments of a tertiary care hospital located in an urban city of South Korea. Only 67 subjects completed the entire study, 34 in the intervention group and 33 controls. The goal of intervention was to reduce waist circumference (WC), body weight (BW) and blood pressure (BP) levels. Before the intervention, demographic variables, WC, BW, BP, fasting plasma glucose (FPG) and serum lipids were measured as pre-test data. The WC, BW, BP, FPG and serum lipids were measured again 12 weeks later. Patients in the intervention group were requested to record their WC, BW, BP, type and amount of diet and exercise in a weekly web-based diary through the Internet or by cellular phone. The researchers sent weekly recommendations on diet and exercise as an intervention to each patient, by both cellular phone and Internet. The intervention was applied for 12 weeks. WC and BW significantly decreased by 3.0 cm and 2.0 kg, respectively, at 12 weeks compared with the baseline in the intervention group. However, the mean changes in the control group significantly increased by 0.9 cm and 0.7 kg. Systolic BP (SBP) and diastolic BP (DBP) significantly decreased by 6.5 and 4.6 mmHg in the intervention group, respectively. The mean changes in the control group were not significant in either SBP or DBP. A significant mean decrease in total cholesterol (TC) was observed for the intervention group by 12.9 mg/dl, while the control group showed a significant mean increase by 1.5mg/dl. Low-density lipoprotein-cholesterol (LDL-C) for the intervention group showed a significant mean decrease 11.3mg/dl. The mean change in the control group was, however, not significant. Web-based individual intervention using both SMS and Internet improved WC, BW, BP, TC, and LDL-C during 12 weeks in post-menopausal women with abdominal obesity.

Background: Children with acute abdominal pain (AP) are frequently assessed in the Emergency Department (ED). Though the majority of patients have benign causes, uncertainty during the physician's initial assessment may result in unnecessary tests and prolonged observation before a definitive disposition decision can be made. A rule-based mobile clinical decision support system, Mobile Emergency Triage-Abdominal Pain (MET-AP), has been developed to recommend an appropriate triage plan (discharge, consult surgery or observe/investigate) early in the ED visit, with the goal of promoting ED efficiencies and improved patient outcomes. Objective: To prospectively evaluate the accuracy of MET-AP to recommend the correct triage plan when used during the initial assessment by staff emergency physicians (EPs) and residents in a tertiary care pediatric ED. Design: Prospective cohort study. Staff EPs and/or residents examined children, aged 1-16 years, with acute, non-traumatic AP of less than 10 days duration. Details of their initial assessment, along with their blinded prediction of the correct triage plan, were recorded electronically. Inter-observer assessments were collected, where possible. Telephone and chart follow-up at 10-14 days was conducted to determine the patient's outcome/diagnosis, and thus the gold standard triage plan appropriate for the patient's visit. Measurements: Accuracy of MET-AP to recommend the correct triage plan (i.e., to match the gold standard plan); accuracy of physicians to predict the correct triage plan; inter-observer agreement between staff EPs and residents for each clinical attribute recorded within MET-AP. Results: Over 8 months, 574 patients with AP completed follow-up (10% appendicitis, 13% other pathology, 77% benign/resolving conditions). For patient assessments by the staff EP (n=457), the MET-AP recommendation was correct for 72% of patients (95% CI's: 67.9-76.1), while the physician's prediction was correct in 70% of cases (65.9-74.2) (p=0.518). However, staff EP triage plans were more conservative than those generated by MET-AP, and a small number of patients whose triage plan should have been "consult surgery" would have been "discharged" by MET-AP. For resident assessments (n=339), MET-AP and physician accuracies were slightly lower, but not statistically different from staff results or from each other. Inter-observer agreement on most attributes was moderate to near perfect. Conclusion: MET-AP shows promise in recommending the correct triage plan with similar overall accuracy to experienced pediatric EPs, but requires further research to improve accuracy and safety. MET-AP can be used on all pediatric ED patients with AP and is capable of producing a triage plan recommendation without requiring a complete set of patient information.

To learn (1) about the kind of experiences that physicians have with participation in healthcare IT development; (2) whether physicians are interested in participating in IT development activities, and if so, how; and (3) the visions that physicians have regarding future IT systems. A web-based questionnaire which was answered by about one-third of the working-age physicians in Finland, which is exceptionally broad and sizeable a sample. This research deals with only a small part of the entire questionnaire. The questions used for this study were both quantitative and qualitative. Statistical methods were applied to the former and content analysis to the latter. The responding physicians were highly critical of their IT systems, and their experiences with the current methods of participation, or rather the lack of it, were quite negative. However, a very significant proportion of the respondents were willing to contribute to IT systems development, contrary to a common assumption that clinicians are disinterested. Visioning of future systems was quite cautious, dealing mainly with usability improvements to the current systems. Major improvements are needed both in the usability of the systems currently in use in Finland and in the collaboration between end-users and developers. Improved methods of participation need to be developed and applied, particularly for the procurement, deployment and on-going development of commercial-off-the-shelf applications.

Failures to follow-up abnormal test results are common in ambulatory care. Information systems could assist providers with abnormal test result tracking, yet little is known about primary care providers attitudes toward outpatient decision support systems. A cross-sectional survey of 216 primary care physicians (PCPs) that utilize a single electronic medical record (EMR) without computer-based clinical decision support. The overall response rate was 65% (140/216). Less than one-third of the respondents were satisfied with their current system to manage abnormal laboratory, radiographs, Pap smear, or mammograms results. Only 15% of providers were satisfied with their system to notify patients of abnormal results. Over 90% of respondents felt automated systems to track abnormal test results would be useful. Seventy-nine percent of our respondents believed that they could comply better with guidelines through electronic clinical reminders. Most PCPs were not satisfied with their methods for tracking abnormal results. Respondents believed that clinical decision support systems (CDSS) would be useful and could improve their ability to track abnormal results.

Purpose: To evaluate the impact of insufficient longitudinal data on the accuracy of a high-throughput clinical phenotyping (HTCP) algorithm for identifying (1) patients with type 2 diabetes mellitus (T2DM) and (2) patients with no diabetes. Methods: Retrospective study conducted at Mayo Clinic in Rochester, Minnesota. Eligible subjects were Olmsted County residents with ≥1 Mayo Clinic encounter in each of three time periods: (1) 2007, (2) from 1997 through 2006, and (3) before 1997 (N = 54,283). Diabetes relevant electronic medical record (EMR) data about diagnoses, laboratories, and medications were used. We employed the HTCP algorithm to categorize individuals as T2DM cases and non-diabetes controls. Considering the full 11 years (1997-2007) as the gold standard, we compared gold-standard categorizations with those using data for 10 subsequent intervals, ranging from 1998-2007 (10-year data) to 2007 (1-year data). Positive predictive values (PPVs) and false-negative rates (FNRs) were calculated. McNemar tests were used to determine whether categorizations using shorter time periods differed from the gold standard. Statistical significance was defined as P < 0.05. Results: We identified 2770 T2DM cases and 21,005 controls when the algorithm was applied using 11-year data. Using 2007 data alone, PPVs and FNRs, respectively, were 70% and 25% for case identification and 59% and 67% for control identification. All time frames differed significantly from the gold standard, except for the 10-year period. Conclusions: The accuracy of the algorithm reduced remarkably as data were limited to shorter observation periods. This impact should be considered carefully when designing/executing HTCP algorithms.

Since clinical management of patients and clinical research are essentially time-oriented endeavours, reasoning about time has become a hot topic in medical informatics. Here we present a method for prognosis of temporal courses, which combines temporal abstractions with case-based reasoning. It is useful for application domains where neither well-known standards, nor known periodicity, nor a complete domain theory exist. We have used our method in two prognostic applications. The first one deals with prognosis of the kidney function for intensive care patients. The idea is to elicit impairments on time, especially to warn against threatening kidney failures. Our second application deals with a completely different domain, namely geographical medicine. Its intention is to compute early warnings against approaching infectious diseases, which are characterised by irregular cyclic occurrences. So far, we have applied our program on influenza and bronchitis. In this paper, we focus on influenza forecast and show first experimental results.

Background: Academic detailing (AD) is the practice of specially trained pharmacists with detailed medication knowledge meeting with physicians to share best practices of prescribing. AD has demonstrated efficacy in positively influencing physicians' prescribing behavior. Nevertheless, a key challenge has been that physicians in rural and remote locations, or physicians who are time challenged, have limited ability to participate in face-to-face meetings with academic detailers, as these specially trained academic detailers are primarily urban-based and limited in numbers. Objective: To determine the feasibility of using information technologies to facilitate communication between academic detailers and physicians (known as Technology-Enabled Academic Detailing or TEAD) through a comparison to traditional face-to-face academic detailing (AD). Specifically, TEAD is compared to AD in terms of the ability to aid physicians in acquiring evidence-informed prescribing information on diabetes-related medications, measured in terms of time efficiency, satisfaction of both physicians and pharmacists, and quality of knowledge exchange. Methods: General Practitioner Physicians (n=105) and pharmacists (n=12) were recruited from across British Columbia. Pharmacists were trained to be academic detailers on diabetes medication usage. Physicians were assigned to one of four intervention groups to receive four academic detailing sessions from trained pharmacists. Intervention groups included: (1) AD only, (2) TEAD only, (3) TEAD crossed over to AD at midpoint, and (4) AD crossed over to TEAD at midpoint. Evaluation included physician-completed surveys before and after each session, pharmacist logs after each detailing session, interviews and focus groups with physicians and pharmacists at study completion, as well as a technical support log to record all phone calls and emails from physicians and pharmacists regarding any technical challenges during the TEAD sessions, or usage of the web portal. Results: Because recruitment was very low for the cross over groups, we analyzed the results in two groups instead: AD only and TEAD only. 354 sessions were conducted (AD=161, TEAD=193). Of these, complete data were available for 300 sessions, which were included in analysis (AD=133, TEAD=167). On average, TEAD sessions were 49min long, and AD sessions 81min long. Overall, physicians enjoyed both modalities of academic detailing (AD and TEAD) because they received information that both reinforced their existing diabetes knowledge and also provided new prescribing insights and approaches. Conclusion: The results suggest that TEAD is an acceptable alternative to AD for providing physicians advice about prescribing. TEAD is more time efficient, facilitates effective knowledge exchange and interprofessional collaboration, and can reach those physicians virtually where face-to-face AD is not possible or practical. Limitations: Due to logistics, physicians were allocated, rather than randomized, to receive AD and/or TEAD.

The Brigham integrated computing system (BICS) provides nearly all clinical, administrative, and financial computing services to Brigham and Women's Hospital, an academic tertiary-care hospital in Boston. The BICS clinical information system includes a very wide range of data and applications, including results review, longitudinal medical records, provider order entry, critical pathway management, operating-room dynamic scheduling, critical-event detection and altering, dynamic coverage lists, automated inpatient summaries, and an online reference library. BICS design emphasizes direct physician interaction and extensive clinical decision support. Impact studies have demonstrated significant value of the system in preventing adverse events and in saving costs, particularly for medications.

From the Hippocratic Oath to the World Medical Association's Declaration of Geneva, physicians have sworn to protect patients' privacy. However, as systems move to more integrated architectures, protecting this medical data becomes more of a challenge. The increase in complexity of IT environments, the aggregation of data, and the desire of other entities to access this data, often 24 h/day x 7 day/week x 365 day/year, is putting serious strains on our ability to maintain its security. This problem cuts across all electronic record sources from patient care records to academic medical research records. In order to address this issue, we are rethinking the way we store, transmit, process, access, and federate patient data from clinical and research applications. Our groups at the University of Michigan are developing a system called the "Honest Broker" to help manage this problem. The Honest Broker will offload the burden of housing identifiable data elements of protected health information (PHI) (e.g., name and address) as well as manage data transfer between clinical and research systems. Lab results and other non-identifiable data will be stored in separate systems with either a research study ID or clinical ID number. This two-component architecture increases the burden on attackers who now need to compromise two systems, one of which is seriously hardened, in order to match health data with a patient's actual identity. While no security system is truly intrusion-proof, this architecture provides a high security choke point reducing the likelihood of a breach. By redesigning the method of integrating clinical care and research, we have enabled projects that would be cost prohibitive to conduct otherwise. The scalability of this mechanism is dependant on nature of the heterogenous nature of the clinical systems serving patients.

The Clinical data repository (CDR) at the University of Virginia Health System is a data warehouse that provides direct access to data for clinical research and effective decision making. We undertook an evaluation of the CDR to understand factors affecting its adoption. We used a theoretical framework that is based on diffusion of innovation theory. Building on validated survey instruments, we developed a questionnaire and conducted interviews of key executive leaders. Fifty-three individuals with logon ids to the CDR completed our questionnaire. Twelve executive leaders were interviewed. The outcome variables were the initial and continued use of the CDR. Independent variables included attributes suggested by diffusion theory (i.e. relative advantage, complexity), knowledge and skills expected to correlate with computer usage, and the influence of communication channels. Our overall response rate was 82%. We identified characteristics of users associated with the initial decision to use the CDR. Compatibility with an individual's skills and work style was associated strongly with satisfaction and continued use. Secondly, the importance of organizational culture and the need for data was illuminated by management interviews. We have shown that diffusion of innovation theory can be used to help understand factors contributing to the success of a data warehouse in a healthcare setting. Our results suggest areas for future research and inquiry as the CDR evolves.

The impact of the ambulatory electronic health record (EHR) on physician productivity is poorly understood. Fear of productivity loss remains a major concern for practitioners and health care delivery organizations and inhibits system adoption. This study describes the changes in physician productivity after the implementation of a commercially available ambulatory EHR system in a large academic multi-specialty physician group. Weill Cornell faculty members implemented on the EpicCare (Epic Systems) EHR between 2001 and 2007 were identified as potential study participants. Monthly visit volume, charges, and work relative value units (wRVUs) were compared pre and post each provider's EHR implementation go-live date. Practitioners who lacked at least 6 months of pre- and post-implementation visit volume and charge data were excluded. Practitioners who did not meet pre-determined system proficiency metrics were additionally identified and became the basis of a non-adopter comparison group. 203 physicians met criteria for the analysis. The eligible providers were divided into an adopter and non-adopter cohort based on system proficiency benchmarks. Those practitioners who adopted the EHR had a statistically significant increase in average monthly patient visit volume of 9 visits per provider per month. The non-adopter cohort's visit volume was statistically unchanged. Both the EHR adopters and non-adopters had statistically significant increases (22% and 16% respectively) in average monthly charges in the post-implementation period. Average monthly wRVUs were statistically unchanged in the non-adopter cohort, but showed a positive and statistically significant increase of 12 wRVUs per provider per month for the adopter group. The EHR adoption group showed an incremental increase in productivity once practitioners achieved 6 or more months experience with the EHR, consistent with a "ramp-up" period. A multivariable regression model did not reveal any association between the post-EHR implementation change in wRVUs and several potential confounding variables, including baseline provider average monthly visit volume and wRVUs, date of system adoption, and specialty categorization. Provider productivity, as measured by patient visit volume, charges, and wRVUs modestly increased for a cohort of multi-specialty providers that adopted a commercially available ambulatory EHR. The productivity gain appeared to become even more pronounced after several months of system experience. This objective data may help persuade apprehensive practitioners that EHR adoption need not harm productivity. The baseline differences in productivity metrics for the adopters and non-adopters in our study suggest that there are fundamental differences in these groups. Further characterizing these differences may help predict EHR adoption success and guide future implementation strategies.