Journal of the American Medical Informatics Association

Published by Oxford University Press (OUP)
Online ISSN: 1527-974X
Publications
Article
Dr. Schleyer asks a number of important questions. These might be summarized as asking why, as a discipline, are we not focusing on improving the acquisition of structured data rather than going through computational acrobatics to extract codified representation from narrative text? Should we not be focusing our efforts to ensure a fully-structured record?
 
Flow diagram of the proposed method.
Performance metrics for the LSP experiment
Article
To develop a system to extract follow-up information from radiology reports. The method may be used as a component in a system which automatically generates follow-up information in a timely fashion. A novel method of combining an LSP (labeled sequential pattern) classifier with a CRF (conditional random field) recognizer was devised. The LSP classifier filters out irrelevant sentences, while the CRF recognizer extracts follow-up and time phrases from candidate sentences presented by the LSP classifier. The standard performance metrics of precision (P), recall (R), and F measure (F) in the exact and inexact matching settings were used for evaluation. Four experiments conducted using 20,000 radiology reports showed that the CRF recognizer achieved high performance without time-consuming feature engineering and that the LSP classifier further improved the performance of the CRF recognizer. The performance of the current system is P=0.90, R=0.86, F=0.88 in the exact matching setting and P=0.98, R=0.93, F=0.95 in the inexact matching setting. The experiments demonstrate that the system performs far better than a baseline rule-based system and is worth considering for deployment trials in an alert generation system. The LSP classifier successfully compensated for the inherent weakness of CRF, that is, its inability to use global information.
 
Article
The purpose of this study was to evaluate the adequacy of the International Classification of Nursing Practice (1) (ICPN) Version 1.0 as a representational model for nursing assessment documentation. To identify representational requirements of nursing assessments, the authors mapped key concepts and semantic relations extracted from standardized and local nursing admission assessment documentation forms/templates and inpatient admission assessment records to the ICNP. Next, they expanded the list of ICNP semantic relations with those obtained from the admission assessment forms/templates. The expanded ICNP semantic relations were then validated against the semantic relations identified from an additional set of admission assessment records and a set of 300 randomly selected North American Nursing Diagnosis Association defining characteristic phrases. The concept coverage of the ICNP was evaluated by mapping the concepts extracted from these sources to the ICNP concepts. The UMLS Methathesaurus was then used to map concepts without exact matches to other American Nursing Association (ANA) recognized terminologies. The authors found that along with the 30 existing ICNP semantic relations, an additional 17 are required for the ICNP to function as a representational model for nursing assessment documentation. Eight hundred and five unique assessment concepts were extracted from all sources. Forty-three percent of these unique assessment concepts had exact matches in the ICNP. An additional 20% had matches in the ICNP classified as narrower, broader, or "other." Of the concepts without exact matches in the ICNP, 81% had exact matches found in other ANA recognized terminologies. The broad concept coverage and the logic-based structure of the ICNP make it a flexible and robust standard. The ICNP provides a framework from which to capture and reuse atomic level data to facilitate evidence-based practice.
 
Article
To develop software infrastructure that will provide support for discovery, characterization, integrated access, and management of diverse and disparate collections of information sources, analysis methods, and applications in biomedical research. An enterprise Grid software infrastructure, called caGrid version 1.0 (caGrid 1.0), has been developed as the core Grid architecture of the NCI-sponsored cancer Biomedical Informatics Grid (caBIG) program. It is designed to support a wide range of use cases in basic, translational, and clinical research, including 1) discovery, 2) integrated and large-scale data analysis, and 3) coordinated study. The caGrid is built as a Grid software infrastructure and leverages Grid computing technologies and the Web Services Resource Framework standards. It provides a set of core services, toolkits for the development and deployment of new community provided services, and application programming interfaces for building client applications. The caGrid 1.0 was released to the caBIG community in December 2006. It is built on open source components and caGrid source code is publicly and freely available under a liberal open source license. The core software, associated tools, and documentation can be downloaded from the following URL: https://cabig.nci.nih.gov/workspaces/Architecture/caGrid. While caGrid 1.0 is designed to address use cases in cancer research, the requirements associated with discovery, analysis and integration of large scale data, and coordinated studies are common in other biomedical fields. In this respect, caGrid 1.0 is the realization of a framework that can benefit the entire biomedical community.
 
Article
Since publication of the human genome in 2003, geneticists have been interested in risk variant associations to resolve the etiology of traits and complex diseases. The International HapMap Consortium undertook an effort to catalog all common variation across the genome (variants with a minor allele frequency (MAF) of at least 5% in one or more ethnic groups). HapMap along with advances in genotyping technology led to genome-wide association studies which have identified common variants associated with many traits and diseases. In 2008 the 1000 Genomes Project aimed to sequence 2500 individuals and identify rare variants and 99% of variants with a MAF of <1%. To determine whether the 1000 Genomes Project includes all the variants in HapMap, we examined the overlap between single nucleotide polymorphisms (SNPs) genotyped in the two resources using merged phase II/III HapMap data and low coverage pilot data from 1000 Genomes. Comparison of the two data sets showed that approximately 72% of HapMap SNPs were also found in 1000 Genomes Project pilot data. After filtering out HapMap variants with a MAF of <5% (separately for each population), 99% of HapMap SNPs were found in 1000 Genomes data. Not all variants cataloged in HapMap are also cataloged in 1000 Genomes. This could affect decisions about which resource to use for SNP queries, rare variant validation, or imputation. Both the HapMap and 1000 Genomes Project databases are useful resources for human genetics, but it is important to understand the assumptions made and filtering strategies employed by these projects.
 
Article
Abstract Public health is a complex discipline that has contributed substantially to improving the health of the population. Public health action involves a variety of interventions and methods, many of which are now taken for granted by the general public. The specific focus and nature of public health interventions continue to evolve, but the fundamental principles of public health remain stable. These principles include a focus on the health of the population rather than of individuals; an emphasis on disease prevention rather than treatment; a goal of intervention at all vulnerable points in the causal pathway of disease, injury, or disability; and operation in a governmental rather than a private context. Public health practice occurs at local, state, and federal levels and involves various professional disciplines. Public health principles and practice are illustrated by a case study example of neural tube defects and folic acid. The application of information science and technology in public health practice provides previously unfathomed opportunities to improve the health of the population. Clinical informaticians and others in the health care system are crucial partners in addressing the challenges and opportunities offered by public health informatics.
 
Article
Described are the changes to ICD-10-CM and PCS and potential challenges regarding their use in the US for financial and administrative transaction coding under HIPAA in 2013. Using author constructed derivative databases for ICD-10-CM and PCS it was found that ICD-10-CM's overall term content is seven times larger than ICD-9-CM: only 3.2 times larger in those chapters describing disease or symptoms, but 14.1 times larger in injury and cause sections. A new multi-axial approach ICD-10-PCS increased size 18-fold from its prior version. New ICD-10-CM and PCS reflect a corresponding improvement in specificity and content. The forthcoming required national switch to these new administrative codes, coupled with nearly simultaneous widespread introduction of clinical systems and terminologies, requires substantial changes in US administrative systems. Through coordination of terminologies, the systems using them, and healthcare objectives, we can maximize the improvement achieved and engender beneficial data reuse for multiple purposes, with minimal transformations.
 
Article
Objective: The objective of this paper is to introduce a new language called ccML, designed to provide convenient pragmatic information to applications using the ISO/EN13606 reference model (RM), such as electronic health record (EHR) extracts editors. EHR extracts are presently built using the syntactic and semantic information provided in the RM and constrained by archetypes. The ccML extra information enables the automation of the medico-legal context information edition, which is over 70% of the total in an extract, without modifying the RM information. Materials and methods: ccML is defined using a W3C XML schema file. Valid ccML files complement the RM with additional pragmatics information. The ccML language grammar is defined using formal language theory as a single-type tree grammar. The new language is tested using an EHR extracts editor application as proof-of-concept system. Results: Seven ccML PVCodes (predefined value codes) are introduced in this grammar to cope with different realistic EHR edition situations. These seven PVCodes have different interpretation strategies, from direct look up in the ccML file itself, to more complex searches in archetypes or system precomputation. Discussion: The possibility to declare generic types in ccML gives rise to ambiguity during interpretation. The criterion used to overcome ambiguity is that specificity should prevail over generality. The opposite would make the individual specific element declarations useless. Conclusion: A new mark-up language ccML is introduced that opens up the possibility of providing applications using the ISO/EN13606 RM with the necessary pragmatics information to be practical and realistic.
 
Categories of Preventive Services 
Summary of the Data Taken From Each of the 16 Studies 
n Odds Ratios and 95% Confidence Intervals Comparing Interventions versus Control for Each Study, Adjusted for Specific Class of Preventive Service (Comparisons Not Directly Addressed in the Studies Are Shown as Open Spaces) 
Odds Ratios and 95% Confidence Intervals for the Effect of Three Interventions versus Control Groups on Each of Six Classes of Preventive Services and From a Combined Analysis That Weights Each Outcome Equally 
Article
Computer-based reminder systems have the potential to change physician and patient behaviors and to improve patient outcomes. We performed a meta-analysis of published randomized controlled trials to assess the overall effectiveness of computer-based reminder systems in ambulatory settings directed at preventive care. Meta-analysis. Searches of the Medline (1966-1994), Nursing and Allied Health (1982-1994), and Health Planning and Administration (1975-1994) databases identified 16 randomized, controlled trials of computer-based reminder systems in ambulatory settings. A weighted mixed effects model regression analysis was used to estimate intervention effects for computer and manual reminder systems for six classes of preventive practices. Adjusted odds ratio for preventive practices. Computer reminders improved preventive practices compared with the control condition for vaccinations (adjusted odds ratio [OR] 3.09; 95% confidence interval [CI] 2.39-4.00), breast cancer screening (OR 1.88; 95% CI 1.44-2.45), colorectal cancer screening (OR 2.25; 95% CI 1.74-2.91), and cardiovascular risk reduction (OR 2.01; 95% CI 1.55-2.61) but not cervical cancer screening (OR 1.15; 95% CI 0.89-1.49) or other preventive care (OR 1.02; 95% CI 0.79-1.32). For all six classes of preventive practices combined the adjusted OR was 1.77 (95% CI 1.38-2.27). Evidence from randomized controlled studies supports the effectiveness of data-driven computer-based reminder systems to improve prevention services in the ambulatory care setting.
 
Logistic regression model characteristics and performance statistics for eight adverse event "classes" 
Methodological overview. (A) Each drug is assigned a label according to their adverse event class, so that each element of the matrix indicates drug i's membership in class j. The fields of this matrix are filled by the user and each column is used as the response variables to train a supervised machine learning algorithm. In this paper we built eight such algorithms for renal impairment, cholesterol, suicide, depression, liver dysfunction, hypertension, hepatotoxicity, and diabetes. (B) Given a particular drug class from (A) (ie, a column), we construct an N by M adverse event frequency matrix, where N is the number of drugs and M is the number of adverse events. Each element of the matrix represents the proportion of reports for drug i which list adverse event j. (C) Since M >> N overfitting the logistic regression model to the training data is a concern. We use feature selection to identify the L most informative adverse events to be used in fitting the logistic regression model. (D) A second adverse event frequency matrix is constructed. The key difference here is that each row represents a drug-pair as opposed to a single drug, as in (B). Note that no data is 
Breakdown of drug-pair predictions for the eight logistic regression models 
Article
Adverse drug events (ADEs) are common and account for 770 000 injuries and deaths each year and drug interactions account for as much as 30% of these ADEs. Spontaneous reporting systems routinely collect ADEs from patients on complex combinations of medications and provide an opportunity to discover unexpected drug interactions. Unfortunately, current algorithms for such "signal detection" are limited by underreporting of interactions that are not expected. We present a novel method to identify latent drug interaction signals in the case of underreporting. We identified eight clinically significant adverse events. We used the FDA's Adverse Event Reporting System to build profiles for these adverse events based on the side effects of drugs known to produce them. We then looked for pairs of drugs that match these single-drug profiles in order to predict potential interactions. We evaluated these interactions in two independent data sets and also through a retrospective analysis of the Stanford Hospital electronic medical records. We identified 171 novel drug interactions (for eight adverse event categories) that are significantly enriched for known drug interactions (p=0.0009) and used the electronic medical record for independently testing drug interaction hypotheses using multivariate statistical models with covariates. Our method provides an option for detecting hidden interactions in spontaneous reporting systems by using side effect profiles to infer the presence of unreported adverse events.
 
Article
( Editor's note : The full text of the original and previously unpublished 1966 historical document is available via an online JAMIA supplement at www.jamia.org; excerpts from representative segments follow below. An ellipsis in square brackets […] has been inserted at each point where text from the original document was omitted. Such text appears in the online “full” version of the document.) I would like to welcome the Public Health Service visitors to the Computer Research Study Section Meeting and to express my personal appreciation for the opportunity to lead this colloquium. It is both a privilege and a challenge to attempt to guide a discussion with such a group of participants and I am certain that it will be an informative experience for me. In the past few years, my work with the members of the Computer Study Section has greatly contributed to my understanding of the problems we are to examine today. The critical and imaginative ideas and the depth of under-standing displayed by these individuals have set a standard which continues to inspire me. It is my hope that this colloquium will conclude with an active discussion. I hope—and expect—to be challenged at many points and feel that we shall all benefit from such an approach. It will be interesting to hear from those among us who may have different philosophies regarding the nature of the objectives and procedures with which we are concerned and, above all, from those present who have had considerable experience in many of the topics we will discuss. This presentation is divided into four sections. 1. A characterization of the basic needs and problems which have brought the computer into medical care. 2. A brief review of certain research and development activities currently underway. 3. A discussion of some of the significant issues encountered in …
 
Article
Medical informatics is in the midst of deep secular changes. In hindsight, these changes have been operating throughout the 1990s; they show no signs of abating. A simple exercise will demonstrate that these changes are not yet widely acknowledged in our field. Before you read further, please free associate in response to the following phrases, and then compare your associations with those below: My associations when I hear “Software in the 1990s” are as follows: The first thing I think of is SCALE. Prior to the 1990s, it was not at all clear how anything in computing was going to scale—e.g., how it was going to be accessed by the majority of computer users. As of 1997, we are starting to take the Internet, Web browsers, and Web search engines for granted. Web search engines are particularly dramatic; whatever their shortcomings, the fact that several systems independently index the World Wide Web (WWW) on a more or less daily basis was not anticipated. After scale, my next association with “Software in the 1990s” is GLOBALIZATION. One can now buy software that is used productively around the world by users who know only their native languages. The economic incentives are clear. If a software product can be used worldwide, it is easier to justify investing in its development, maintenance, and enhancement than if that same product could only be used by one country or by users of one language. My third “Software in the 1990s” association was easier to foresee: namely, it is TOUGH TO SURVIVE AS A NICHE. Microeconomic theory predicts that new markets can support many suppliers of …
 
Article
The continuing development of the field of medical informatics has raised new questions and placed before us new dilemmas. Spurred by the proliferation of information systems to support the broad missions of our institutions, and the evolution of these systems from luxuries to necessities, organizational issues have assumed increasing prominence. Among a dazzling array of organizational issues now before us is the tension between the long-standing academic role of informatics groups within medical centers and the ever-expanding service role. In the academic role, we seek the knowledge to create improved technology and to train the next generation of informatics researchers. In the service role, we seek to put existing technology, developed internally or purchased from vendors, to best use across the full scope of medical center activities. The dilemma before us is not whether both roles are important—the answer to that is clear—but rather how to organize ourselves within our institutions to address both of them. How much organizational distance should exist between the people who carry out these different roles, and who should direct their efforts? Most academic medical centers are actively searching for answers to these organizational questions, and many AMIA members are engaged in this pursuit. The answers obtained will be of profound consequence for our field. The salience of this issue directed its selection as the focus of the ACMI Debate at the closing session of the 1997 AMIA Fall Symposium. The purpose of the debate was not to generate a universal answer, for no such answer exists, but rather to illuminate the many factors that must be considered as our institutions search for an appropriate organizational model. To frame the debate, we intentionally polarized the issue around a specific proposition: Resolved: Academic medical centers should have a single unit responsible for information systems supporting the …
 
Article
To evaluate the patterns of e-Health use over a four-year period and the characteristics of users. Longitudinal, population-based study (1999-2002) of members of a prepaid integrated delivery system. Available e-Health services included ordering prescription drug refills, scheduling appointments, and asking medical questions. Rates of known access to e-Health services, and of e-Health use each quarter. The number of members with known e-Health access increased from 51,336 (1.6%) in 1999 to 324,522 (9.3%), in 2002. The percentage of households in which at least one person in the household had access increased from 2.7% to 14.1%. Among the subjects with known access, the percentage of subjects that used e-Health at least once increased from 25.7% in 1999 to 36.2% in 2002. In the multivariate analysis, subjects who had a low expected clinical need, were nonwhite, or lived in low socioeconomic status (SES) neighborhoods were less likely to have used e-Health services in 2002. Disparities by race/ethnicity and SES persisted after controlling for access to e-Health and widened over time. Access to and use of e-Health services are growing rapidly. Use of these services appears to be greatest among persons with more medical need. The majority of subjects, however, do not use any e-Health services. More research is needed to determine potential reasons for disparities in e-Health use by race/ethnicity and SES as well as the implications of these disparities on clinical outcomes.
 
Article
The 1999 debate of the American College of Medical Informatics focused on the proposition that medical informatics and nursing informatics are distinctive disciplines that require their own core curricula, training programs, and professional identities. Proponents of this position emphasized that informatics training, technology applications, and professional identities are closely tied to the activities of the health professionals they serve and that, as nursing and medicine differ, so do the corresponding efforts in information science and technology. Opponents of the proposition asserted that informatics is built on a re-usable and widely applicable set of methods that are common to all health science disciplines, and that "medical informatics" continues to be a useful name for a composite core discipline that should be studied by all students, regardless of their health profession orientation.
 
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Article
Health care leaders emphasize the need to include information technology and informatics concepts in formal education programs, yet integration of informatics into health educational programs has progressed slowly. The AMIA 1999 Spring Congress was held to address informatics educational issues across health professions, including the educational needs in the various health professions, goals for health informatics education, and implementation strategies to achieve these goals. This paper presents the results from AMIA work groups focused on informatics education for non-informatics health professionals. In the categories of informatics needs, goals, and strategies, conference attendees suggested elements in these areas: educational responsibilities for faculty and students, organizational responsibilities, core computer skills and informatics knowledge, how to learn informatics skills, and resources required to implement educational strategies.
 
Article
Development of public health informatics applications often requires the integration of multiple data sources. This process can be challenging due to issues such as different file formats, schemas, naming systems, and having to scrape the content of web pages. A potential solution to these system development challenges is the use of Web 2.0 technologies. In general, Web 2.0 technologies are new internet services that encourage and value information sharing and collaboration among individuals. In this case report, we describe the development and use of Web 2.0 technologies including Yahoo! Pipes within a public health application that integrates animal, human, and temperature data to assess the risk of West Nile Virus (WNV) outbreaks. The results of development and testing suggest that while Web 2.0 applications are reasonable environments for rapid prototyping, they are not mature enough for large-scale public health data applications. The application, in fact a “systems of systems,” often failed due to varied timeouts for application response across web sites and services, internal caching errors, and software added to web sites by administrators to manage the load on their servers. In spite of these concerns, the results of this study demonstrate the potential value of grid computing and Web 2.0 approaches in public health informatics.
 
Article
Healthcare and biomedical research are part of a global electronic ecosystem in which social media, mobile devices, and increasing public engagement have been playing game-changing roles. ‘Web 2.0’ has been used to describe a highly interactive virtual environment in which geographic, cultural, and language barriers are overcome by people's needs to form networks to communicate and collaborate due to common interests. Preventing or alleviating the burden of disease is a most powerful global common goal; hence it is no surprise that there are increasing reports describing informatics advances that enable ‘Health 2.0.’ For example, McCoy ( see page 713 ) describes how her team successfully used crowd sourcing (ie, outsourcing of a particular task to a large community of people) to construct a knowledge base of associations between medication and problems, in contrast to more traditional mechanisms based on a small panel of experts. The latter model is described by Phansalkar ( see page 735 ), who reports on the construction of a knowledge base …
 
Article
In September 2000, the Agency for Healthcare Quality and Research and the American Academy of Pediatrics Center for Child Health Research sponsored a meeting of experts and knowledgeable stakeholders to identify 1) the special information needs of pediatric care and 2) health service research questions related to the use of information technology in children's health care. Technologies that support the care of children must address issues related to growth and development, children's changing physiology, and the unique diseases of children and interventions of pediatric care. Connectivity and data integration are particular concerns for child health care workers. Consumer health information needs for this population extend beyond the needs of one individual to the needs of the family. Recommendations of the attendees include rapid implementation of features in electronic health information systems that support pediatric care and involvement of child health experts in policy making, standards setting, education, and advocacy. A proposed research agenda should address both effectiveness and costs of information technology, with special consideration for the needs of children, the development and evaluation of clinical decision support in pediatric settings, understanding of the epidemiology of iatrogenic injury in childhood, supplementation of vocabulary standards with pediatrics-specific terminology, and improvement in health care access for children, using telemedicine.
 
Article
The AMIA 2001 Spring Congress brought together members of the the public health and informatics communities to develop a national agenda for public health informatics. Discussions of funding and governance; architecture and infrastructure; standards and vocabulary; research, evaluation, and best practices; privacy, confidentiality, and security; and training and workforce resulted in 74 recommendations with two key themes-that all stakeholders need to be engaged in coordinated activities related to public health information architecture, standards, confidentiality, best practices, and research; and that informatics training is needed throughout the public health workforce. Implementation of this consensus agenda will help promote progress in the application of information technology to improve public health.
 
Article
For those of us who have dedicated our careers to medical informatics, it is easy to feel over-stimulated in the current times. Moore's Law has seemingly been generalized, beyond the hardware we use, to embrace every aspect of our professional lives. Opportunities to apply our science seem to double annually, in ways unforeseeable as recently as five years ago. A field that once was clearly focused on systems to support the care of hospitalized and clinic patients has extended its reach to health information resources for consumers, systems to enhance and protect public health, and systems that support research in genomics and proteomics. We have spawned subfields denoted by prefixes or qualifying phrases, such as “public health informatics,” to mark this trend. Moreover, a field that was solidly rooted in academic medical centers now finds professional representation in for-profit corporations both large and small, in government agencies, and in foundations and professional societies. The field has acquired a distinct entrepreneurial spirit, not at all unwelcome but somehow new and unfamiliar. As our relatively small field engages new problems in new settings, these novel activities are accompanied by an inevitable sense of dilution reflected in specific concerns about our collective future. If we expand our representation into new and diverse environments—as informatics engages Big Science, Big Government, and Big Industry—will there be a sufficient number of us in each of these environments to be influential? Will we retain our own culture or will we dissolve into the cultures of these expanding work settings? Will the information technology deployed in these settings build on the generalizable solutions we have developed and the experience we have accrued, or will these solutions be reinvented? Reflecting this concern, our name—“informatics”—has metamorphosed into something novel and unintended: in many circles “informatics” is coming to mean “anything …
 
Article
The 2001 debate of the American College of Medical Informatics focused on the proposition that national regulatory mandate of computer-based provider order entry (CPOE), to take effect by the end of 2005, portends greater benefit than risk for health care delivery. Both sides accepted that provider order entry offers potential benefit. Those supporting the proposition emphasized public safety, noting that payers have little economic incentive to pay for quality and that a mandate would force vendors to improve the usability and value of their systems. They argued that the mandate would align the economic incentives to finally allow CPOE to be widely adopted. Those opposing the proposition emphasized the risks resulting from a mandate, including the direct implementation costs, the logistic issues of implementation, and the cost of failed implementations. They also noted the potential for errors introduced by the systems themselves and the fact that the safety and utility of commercially available CPOE products have yet to be proved.
 
Article
To determine the availability of inpatient computerized physician order entry in U.S. hospitals and the degree to which physicians are using it. Combined mail and telephone survey of 964 randomly selected hospitals, contrasting 2002 data and results of a survey conducted in 1997. Availability: computerized order entry has been installed and is available for use by physicians; inducement: the degree to which use of computers to enter orders is required of physicians; participation: the proportion of physicians at an institution who enter orders by computer; and saturation: the proportion of total orders at an institution entered by a physician using a computer. The response rate was 65%. Computerized order entry was not available to physicians at 524 (83.7%) of 626 hospitals responding, whereas 60 (9.6%) reported complete availability and 41 (6.5%) reported partial availability. Of 91 hospitals providing data about inducement/requirement to use the system, it was optional at 31 (34.1%), encouraged at 18 (19.8%), and required at 42 (46.2%). At 36 hospitals (45.6%), more than 90% of physicians on staff use the system, whereas six (7.6%) reported 51-90% participation and 37 (46.8%) reported participation by fewer than half of physicians. Saturation was bimodal, with 25 (35%) hospitals reporting that more than 90% of all orders are entered by physicians using a computer and 20 (28.2%) reporting that less than 10% of all orders are entered this way. Despite increasing consensus about the desirability of computerized physician order entry (CPOE) use, these data indicate that only 9.6% of U.S. hospitals presently have CPOE completely available. In those hospitals that have CPOE, its use is frequently required. In approximately half of those hospitals, more than 90% of physicians use CPOE; in one-third of them, more than 90% of orders are entered via CPOE.
 
Article
The 2002 Olympic Winter Games were held in Utah from February 8 to March 16, 2002. Following the terrorist attacks on September 11, 2001, and the anthrax release in October 2001, the need for bioterrorism surveillance during the Games was paramount. A team of informaticists and public health specialists from Utah and Pittsburgh implemented the Real-time Outbreak and Disease Surveillance (RODS) system in Utah for the Games in just seven weeks. The strategies and challenges of implementing such a system in such a short time are discussed. The motivation and cooperation inspired by the 2002 Olympic Winter Games were a powerful driver in overcoming the organizational issues. Over 114,000 acute care encounters were monitored between February 8 and March 31, 2002. No outbreaks of public health significance were detected. The system was implemented successfully and operational for the 2002 Olympic Winter Games and remains operational today.
 
Article
Effective response to natural or man-made disasters (i.e., terrorism) is predicated on the ability to communicate among the many organizations involved. Disaster response exercises enable disaster planners and responders to test procedures and technologies and incorporate the lessons learned from past disasters or exercises. On May 31 and June 1, 2002, one such exercise event took place at the Camp Lejeune Marine Corps Base in Jacksonville, North Carolina. During the exercise, East Carolina University tested: (1) in-place Telehealth networks and (2) rapidly deployable communications, networking, and data collection technologies such as satellite communications, local wireless networking, on-scene video, and clinical and environmental data acquisition and telemetry. Exercise participants included local, county, state, and military emergency medical services (EMS), emergency management, specialized response units, and local fire and police units. The technologies and operations concepts tested at the exercise and recommendations for using telehealth to improve disaster response are described.
 
Article
Background: The Secretary of Health and Human Services recently released a report calling for the nation to create a national health information network (NHIN) that would interconnect Regional Health Information Organizations (RHIOs). These RHIOs, which others have called Local or Regional Health Information Infrastructures (LHII), would in turn interconnect local as well as national health information resources. Little data exist about the activities taking place in communities to create LHIIs. Approach: The authors analyzed data that communities submitted in response to a request for capabilities issued by the Foundation for eHealth as part of their Connecting Communities for Better Health program using descriptive statistics and subjective evaluation. Impression: The authors analyzed data from 134 responses from communities in 42 states and the District of Columbia. Communities are enthusiastic about moving forward with health information exchange to create LHIIs to improve the efficiency, quality, and safety of care. They have identified significant local sources of investment and plan to use some clinical data standards but not as broadly as was expected. The communities have not yet developed the specific technical approaches or the sustainable business models that will be required. Many communities are interested in creating an LHII and are developing the leadership commitment needed to translate that interest into an operational reality. Clinical information standards can be incorporated into a community's plans as often as they need to be. Communities have to overcome funding issues, develop deeper understanding of the technical and organizational issues, and aggressively share their learning to succeed within their community and to help other communities succeed.
 
Article
Despite growing support for the adoption of electronic health records (EHR) to improve U.S. healthcare delivery, EHR adoption in the United States is slow to date due to a fundamental failure of the healthcare information technology marketplace. Reasons for the slow adoption of healthcare information technology include a misalignment of incentives, limited purchasing power among providers, variability in the viability of EHR products and companies, and limited demonstrated value of EHRs in practice. At the 2004 American College of Medical Informatics (ACMI) Retreat, attendees discussed the current state of EHR adoption in this country and identified steps that could be taken to stimulate adoption. In this paper, based upon the ACMI retreat, and building upon the experiences of the authors developing EHR in academic and commercial settings we identify a set of recommendations to stimulate adoption of EHR, including financial incentives, promotion of EHR standards, enabling policy, and educational, marketing, and supporting activities for both the provider community and healthcare consumers.
 
Article
This study sought to define the extent of utilization of 12 types of electronic information system (EIS) function in U.S. nursing homes (NH), to relate EIS utilization to selected facility characteristics and to contrast these findings to previous estimates of EIS use in NH. This study used data from the National Nursing Home Survey (NNHS), a nationally representative, cross-sectional sample of U.S. NH. Data on current use of EIS in 12 functional areas, including administrative and resident care activities, were collected. Information was also collected on facility characteristics including ownership, bed size, and whether the facility was a member of a chain. Essentially all (99.6%) U.S. NH had >or=1 EIS, a figure that was driven by the nearly universal use of EIS for Minimum Data Set (MDS) reporting (96.4%) and for billing (95.4%). Nearly 43% of U.S. NH had EIS for medical records, including nurse's notes, physician notes, and MDS forms. EIS use ranged from a high of 79.6% for admission, transfer, and discharge to a low of 17.6% for daily care by certified nursing assistants (CNAs). Ownership, membership in a chain, and bed size were associated with use of selected EIS. Larger facilities and those that were part of a chain used more EIS than smaller standalone facilities. In 2004, NH use of EIS for functions other than MDS and billing was highly variable, but considerably higher than previous estimates.
 
Article
To determine the availability of computerized physician order entry (CPOE) and electronic medical record (EMR) systems in teaching and general hospitals in the Republic of Korea. A combined mail and telephone survey of 283 hospitals. The surveys assessed the availability of CPOE and EMRs in the hospitals, as well as inducement, participation, and saturation regarding CPOE use by physicians. A total of 122 (43.1%) hospitals responded to the survey. The complete form of CPOE was available in 98 (80.3%) hospitals. The use of CPOE was mandatory in 92 (86.0%) of the 107 hospitals that responded to the questions regarding the requirement of CPOE use. In 85 (79.4%) of the hospitals in which CPOE was in use, more than 90% of physicians used the system. In addition, physicians entered more than 90% of their total orders through CPOE in 87 (81.3%) hospitals. In contrast, a complete EMR system was available in only 11 (9.0%) of the hospitals. Of the teaching and general hospitals in the Republic of Korea that responded to the survey, the majority (80.3%) have CPOE systems, and a complete EMR system is available in only 9%.
 
Article
Objective: Electronic health records (EHRs) have potential to improve quality and safety, but many physicians do not use these systems to full capacity. The objective of this study was to determine whether this usage gap is narrowing over time. Design: Follow-up mail survey of 1,144 physicians in Massachusetts who completed a 2005 survey. Measurements: Adoption of EHRs and availability and use of 10 EHR functions. Results: The response rate was 79.4%. In 2007, 35% of practices had EHRs, up from 23% in 2005. Among practices with EHRs, there was little change between 2005 and 2007 in the availability of nine of ten EHR features; the notable exception was electronic prescribing, reported as available in 44.7% of practices with EHRs in 2005 and 70.8% in 2007. Use of EHR functions changed inconsequentially, with more than one out of five physicians not using each available function regularly in both 2005 and 2007. Only electronic prescribing increased substantially: in 2005, 19.9% of physicians with this function available used it most or all the time, compared with 42.6% in 2007 (p < 0.001). Conclusions: By 2007, more than one third of practices in Massachusetts reported having EHRs; the availability and use of electronic prescribing within these systems has increased. In contrast, physicians reported little change in the availability and use of other EHR functions. System refinements, certification efforts, and health policies, including standards development, should address the gaps in both EHR adoption and the use of key functions.
 
Article
This report provides updated estimates on use of electronic medical records (EMRs) in US home health and hospice (HHH) agencies, describes utilization of EMR functionalities, and presents novel data on telemedicine and point of care documentation (PoCD) in this setting. Nationally representative, cross-sectional survey of US HHH agencies conducted in 2007. Data on agency characteristics, current use of EMR systems as well as use of telemedicine and PoCD were collected. In 2007, 43% of US HHH agencies reported use of an EMR system. Patient demographics (40%) and clinical notes (34%) were the most commonly used EMR functions among US HHH agencies. Only 20% of agencies with EMR systems had health information sharing functionality and about half of them used it. Telemedicine was used by 21% of all HHH agencies, with most (87%) of these offering home health services. Among home health agencies using telemedicine, greater than 90% used telephone monitoring and about two-thirds used non-video monitoring. Nearly 29% of HHH agencies reported using electronic PoCD systems, most often for Outcome and Assessment Information Set (OASIS) data capture (79%). Relative to for-profit HHH agencies, non-profit agencies used considerably more EMR (70% vs 28%, p<0.001) and PoCD (63% vs 9%, p<0.001). Between 2000 and 2007, there was a 33% increase in use of EMR among HHH agencies in the US. In 2007, use of EMR and PoCD technologies in non-profit agencies was significantly higher than for-profit ones. Finally, HHH agencies generally tended to use available EMR functionalities, including health information sharing.
 
Article
The American College of Medical Informatics (ACMI) is an honorary society established to recognize those who have made sustained contributions to the field. Its highest award, for lifetime achievement and contributions to the discipline of medical informatics, is the Morris F. Collen Award. Dr. Collen's own efforts as a pioneer in the field stand out as the embodiment of creativity, intellectual rigor, perseverance, and personal integrity. The Collen Award is given each year, when appropriate, to pioneers in the field of Medical Informatics who best exemplify the teaching and practice of Morris Collen. In 2007, the College was proud to present the Collen Award to William Wallace Stead (Figure 1). Throughout his career, Dr. Bill Stead, has been able to visualize better ways of achieving the purpose of work, and then to drop to ground level to figure out how to execute on the next step in that direction. Figure 1 William Wallace Stead 2005. Bill Stead was born in Durham NC in 1948 as third child to Eugene Anson Stead, Jr. and Evelyn Emogene Selby. Gene Stead was Chair of Medicine at Duke. He trained a generation of independent thinkers and constantly broke the mold; changing the Duke curriculum to replace memory with research, using the Cardiovascular Databank to improve practice, and launching the physician assistant profession to increase access to care. Evelyn was at Gene's side every step; raising Nancy, Lucy, and Bill, co-authoring an early low fat cook book, and editing the journals Gene took on. Every person or event she touched became special. To many observers through the years, it seemed that Gene and Bill Stead were practically the same person. As Harry Jacobson, MD, Vice-Chancellor, Vanderbilt University Medical Center, observed, “They had both a loving relationship, but a mutual respect—and a mutual curiosity, intellectual curiosity about what …
 
Article
The American College of Medical Informatics (ACMI), is “a college of elected fellows from the United States and abroad who have made significant and sustained contributions to the field of medical informatics” and is a component of the American Medical Informatics Association (AMIA). Over the last few years in its winter symposium, ACMI has discussed a variety of issues related to the adoption and deployment of electronic health records (EHRs). Beginning in winter 2004, ACMI addressed what would be needed to promote greater adoption of electronic health records. The recommendations led to AMIA's “Got EHR?” initiative (www.amia.org/gotehr) and a series of articles summarizing the ACMI participants' recommendations.1–4 In 2005, the ACMI symposium focused on personal health records (PHRs), and the resulting article outlined recommendations for the deployment of PHRs, an area that is now showing increasing development nationwide.5 In 2006, with the growing interest in clinical decision support (see AMIA's Clinical Decision Support Roadmap initiative http://www.amia.org/inside/initiatives/cds/), ACMI addressed the knowledge management that would be needed for effective broad-based use of clinical decision support systems. These recommendations were presented at the 2006 AHRQ Patient Safety and Healthcare …
 
Article
Informatics and information technology hold the promise of a consumer-centered health enterprise--one that provides quality care at a cost society is willing to pay; one where need-based, adaptive, competency-based learning results in cost-effectiveness of health education; one where team-based health and learning on demand, coupled with monitoring of process outcomes and network access to expertise, guarantee quality. The barriers to this promise are the professional guilds, the cross-subsidies that support the health enterprise of 1998, and the lack of respect for privacy. Collectively, the informatics community needs to develop a compelling vision that will galvanize the health community to action. If the health community does not step up to this challenge, consumers will take advantage of disintermediation. Empowered by the network, they will go outside the system into hands that meet their needs.
 
Article
By the year 2008, a major reorganization of health care services in the United States will have evolved from the solo- and group-practice models of the 1940s, with fee-for-service and insurer-indemnification financing and paper-based information systems, to nationwide managed care plans employing enhanced computer-based information systems.
 
Article
The American College of Medical Informatics is an honorary society established to recognize those who have made sustained contributions to the field. Its highest award, for lifetime achievement and contributions to the discipline now known more inclusively as biomedical informatics, is the Morris F Collen Award. Dr. Collen's own efforts as a pioneer in the field stand as the embodiment of creativity, intellectual rigor, perseverance, and personal integrity. At most once a year, the College gives its highest recognition to an individual whose attainments have, throughout a career, substantially advanced the science and art of biomedical informatics. In 2008, the College was proud to present the Collen Award to Robert A. Greenes, MD, PhD (Figure 1). ‘Bob’ Greenes, who like Dr. Collen himself was one of the pioneers in biomedical informatics, has had multiple achievements as a physician, computer scientist, researcher, educator, and eloquent spokesperson for the field. His career contributions make him most deserving of the recognition embodied in the Collen Award. Figure 1 Robert A. Greenes, M.D., PhD 2008 Collen Award Recipient. Bob was born on June 17, 1940 in Cleveland, OH. His parents owned a hardware store in the Polish neighborhood where he and his sister grew up. Upon graduation from Cleveland Heights High School, Bob did undergraduate work at the University of Michigan, where he majored in zoology and took a course in computing (Fig 2). He entered Harvard Medical School …
 
Input e output model of unintended consequences. 
Article
Federal legislation (Health Information Technology for Economic and Clinical Health (HITECH) Act) has provided funds to support an unprecedented increase in health information technology (HIT) adoption for healthcare provider organizations and professionals throughout the U.S. While recognizing the promise that widespread HIT adoption and meaningful use can bring to efforts to improve the quality, safety, and efficiency of healthcare, the American Medical Informatics Association devoted its 2009 Annual Health Policy Meeting to consideration of unanticipated consequences that could result with the increased implementation of HIT. Conference participants focused on possible unintended and unanticipated, as well as undesirable, consequences of HIT implementation. They employed an input-output model to guide discussion on occurrence of these consequences in four domains: technical, human/cognitive, organizational, and fiscal/policy and regulation. The authors outline the conference's recommendations: (1) an enhanced research agenda to guide study into the causes, manifestations, and mitigation of unintended consequences resulting from HIT implementations; (2) creation of a framework to promote sharing of HIT implementation experiences and the development of best practices that minimize unintended consequences; and (3) recognition of the key role of the Federal Government in providing leadership and oversight in analyzing the effects of HIT-related implementations and policies.
 
Medication extraction system architecture diagram. CRF, conditional random fields; SVM, support vector machines.
Article
Medication information comprises a most valuable source of data in clinical records. This paper describes use of a cascade of machine learners that automatically extract medication information from clinical records. Authors developed a novel supervised learning model that incorporates two machine learning algorithms and several rule-based engines. Evaluation of each step included precision, recall and F-measure metrics. The final outputs of the system were scored using the i2b2 workshop evaluation metrics, including strict and relaxed matching with a gold standard. Evaluation results showed greater than 90% accuracy on five out of seven entities in the name entity recognition task, and an F-measure greater than 95% on the relationship classification task. The strict micro averaged F-measure for the system output achieved best submitted performance of the competition, at 85.65%. Clinical staff will only use practical processing systems if they have confidence in their reliability. Authors estimate that an acceptable accuracy for a such a working system should be approximately 95%. This leaves a significant performance gap of 5 to 10% from the current processing capabilities. A multistage method with mixed computational strategies using a combination of rule-based classifiers and statistical classifiers seems to provide a near-optimal strategy for automated extraction of medication information from clinical records.
 
Article
The American College of Medical Informatics is an honorary society established to recognize those who have made sustained contributions to the field. Its highest award, for lifetime achievement and contributions to the discipline of medical informatics, is the Morris F Collen Award. Dr Collen's own efforts as a pioneer in the field stand out as the embodiment of creativity, intellectual rigor, perseverance, and personal integrity. The Collen Award, given once a year, honors an individual whose attainments have, throughout a whole career, substantially advanced the science and art of biomedical informatics. In 2009, the college was proud to present the Collen Award to Betsy Humphreys, MLS, deputy director of the National Library of Medicine. Ms Humphreys has dedicated her career to enabling more effective integration and exchange of electronic information. Her work has involved new knowledge sources and innovative strategies for advancing health data standards to accomplish these goals. Ms Humphreys becomes the first librarian to receive the Collen Award. Dr Collen, on the occasion of his 96th birthday, personally presented the award to Ms Humphreys.
 
Test set performance for the three tasks
Concepts Task feature contributions
Performance for feature accumulations in the Relations Task
Article
As clinical text mining continues to mature, its potential as an enabling technology for innovations in patient care and clinical research is becoming a reality. A critical part of that process is rigid benchmark testing of natural language processing methods on realistic clinical narrative. In this paper, the authors describe the design and performance of three state-of-the-art text-mining applications from the National Research Council of Canada on evaluations within the 2010 i2b2 challenge. The three systems perform three key steps in clinical information extraction: (1) extraction of medical problems, tests, and treatments, from discharge summaries and progress notes; (2) classification of assertions made on the medical problems; (3) classification of relations between medical concepts. Machine learning systems performed these tasks using large-dimensional bags of features, as derived from both the text itself and from external sources: UMLS, cTAKES, and Medline. Performance was measured per subtask, using micro-averaged F-scores, as calculated by comparing system annotations with ground-truth annotations on a test set. The systems ranked high among all submitted systems in the competition, with the following F-scores: concept extraction 0.8523 (ranked first); assertion detection 0.9362 (ranked first); relationship detection 0.7313 (ranked second). For all tasks, we found that the introduction of a wide range of features was crucial to success. Importantly, our choice of machine learning algorithms allowed us to be versatile in our feature design, and to introduce a large number of features without overfitting and without encountering computing-resource bottlenecks.
 
Article
While much attention has been paid to the short-term impact that widespread adoption of health information technology (health IT) will have on the healthcare system, there is a corresponding need to look at the long-term effects that extant policies may have on health IT system resilience, innovation, and related ethical, social/legal issues. The American Medical Informatics Association's 2010 Health Policy Conference was convened to further the national discourse on the issues surrounding these longer-term considerations. Conference participants self-selected into three broad categories: resilience in healthcare and health IT; ethical, legal, and social challenges; and innovation, adoption, and sustainability. The discussions about problem areas lead to findings focusing on the lack of encouragement for long-term IT innovation that may result from current health IT policies; the potential impact of uneven adoption of health IT based on the exclusions of the current financial incentives; the weaknesses of contingency and risk mitigation planning that threaten system resilience; and evolving standards developed in response to challenges relating to the security, integrity, and availability of electronic health information. This paper discusses these findings and also offers recommendations that address the interwoven topics of innovation, resilience, and adoption. The goal of this paper is to encourage public and private sector organizations that have a role in shaping health information policy to increase attention to developing a national strategy that assures that health IT innovation and resilience are not impeded by shorter-term efforts to implement current approaches emphasizing adoption and meaningful use of electronic health records.
 
Article
Following the January 2010 earthquake in Haiti, the Israel Defense Force Medical Corps dispatched a field hospital unit. A specially tailored information technology solution was deployed within the hospital. The solution included a hospital administration system as well as a complete electronic medical record. A light-weight picture archiving and communication system was also deployed. During 10 days of operation, the system registered 1111 patients. The network and system up times were more than 99.9%. Patient movements within the hospital were noted, and an online command dashboard screen was generated. Patient care was delivered using the electronic medical record. Digital radiographs were acquired and transmitted to stations throughout the hospital. The system helped to introduce order in an otherwise chaotic situation and enabled adequate utilization of scarce medical resources by continually gathering information, analyzing it, and presenting it to the decision-making command level. The establishment of electronic medical records promoted the adequacy of medical treatment and facilitated continuity of care. This experience in Haiti supports the feasibility of deploying information technologies within a field hospital operation. Disaster response teams and agencies are encouraged to consider the use of information technology as part of their contingency plans.
 
Top-cited authors
David W Bates
  • Brigham and Women's Hospital
Christopher G Chute
  • Johns Hopkins Medicine
Joshua C Denny
  • Vanderbilt University
Ozlem Uzuner
  • George Mason University
Guergana Savova
  • Harvard Medical School