Paul D. Clayton’s research while affiliated with Columbia University and other places

The Arden Syntax originated in the 1980's, when several knowledge-based systems began to show promise, but researchers recognized the burden of recreating these systems at every institution. Derived initially from Health Evaluation through Logical Processing (HELP) and the Regenstrief Medical Record System (RMRS), the Arden Syntax defines medical logic that can be encoded as independent rules, such as reminders and alerts, with the hope of creating a public library of rules. It was first vetted at an informatics retreat held in 1989 at Columbia University's Arden Homestead. The syntax was intended to be readable by clinician experts but to provide powerful array processing, which was derived largely a programming language called APL. The syntax was improved and implemented by a number of researchers and vendors in the early 1990's and was initially adopted by the consensus standards organization, the American Society for Testing and Materials. Copyright © 2015 Elsevier B.V. All rights reserved.

To investigate whether health-related quality-of-life (HRQoL) scores in a primary care population can be used as a predictor of future hospital utilization and mortality. Prospective cohort study measuring Short Form 12 (SF-12) scores obtained using a mailed survey. SF-12 scores, age, and a comorbidity score were used to predict hospitalization and mortality rate using multivariable logistic regression and Cox proportional hazards during the ensuing 28-month period for elderly patients. Intermountain Health Care, a large integrated-delivery network serving a population of more than 150,000 seniors. Participants were senior patients who had one or more chronic diseases, were community dwelling, and were initially treated in primary care clinics. SF-12 survey Version 1. Seven thousand seventy-six surveys were sent to eligible participants; 3,042 (43%) were returned. Of the returned surveys, 2,166 (71%) were complete and scoreable. For the respondent group, a multivariable analysis demonstrated that older age, male sex, higher comorbidity score, and lower mental and physical summary measures of SF-12 predicted higher mortality and hospitalization. On average, nonresponders were older and had higher comorbidity scores and mortality rates than responders. The SF-12 survey provided additional predictive ability for future hospitalizations and mortality. Such predictive ability might facilitate preemptive interventions that would change the course of disease in this segment of the population. However, nonresponder bias may limit the utility of mailed SF-12 surveys in certain populations.

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.

"Infobuttons" have been proposed as a potential solution for lowering access barriers to on-line information resources at the point-of-care. At Intermountain Healthcare, infobuttons have been available to clinicians for over 4 years. The current implementation of infobuttons is based on a software component called "E-resources Manager,' allowing new infobuttons to be configured without requiring any programming. Infobuttons are implemented in the problem list, laboratory results, and medication order entry modules of HELP2, our web-based Clinical Information System. During the past four years, infobuttons were used 53,127 times by 2,611 unique users. Medication order entry infobuttons were the most commonly used. The continuous growth in use since the initial release confirms the usefulness of infobuttons. However, additional research and development is still needed before full benefits can be achieved within all our clinical systems.

To determine how the addition of generalist care managers and collaborative information technology to an ambulatory team affects the care of patients with diabetes. Multiple ambulatory clinics within Intermountain Health Care (IHC), a large integrated delivery network. A retrospective cohort study comparing diabetic patients treated by generalist care managers with matched controls was completed. Exposure patients had one or more contacts with a care manager; controls were matched on utilization, demographics, testing, and baseline glucose control. Using role-specific information technology to support their efforts, care managers assessed patients' readiness for change, followed guidelines, and educated and motivated patients. Patient data collected as part of an electronic patient record were combined with care manager-created databases to assess timely testing of glycosylated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels and changes in LDL and HbA1c levels. In a multivariable model, the odds of being overdue for testing for HbA1c decreased by 21 percent in the exposure group (n=1,185) versus the control group (n=4,740). The odds of being tested when overdue for HbA1c or LDL increased by 49 and 26 percent, respectively, and the odds of HbA1c <7.0 percent also increased by 19 percent in the exposure group. The average HbA1c levels decreased more in the exposure group than in the controls. The effect on LDL was not significant. Generalist care managers using computer-supported diabetes management helped increase adherence to guidelines for testing and control of HbA1c levels, leading to improved health status of patients with diabetes.

At Intermountain Health Care, we evaluated whether physicians in an ambulatory setting will voluntarily choose to enter data directly into an electronic health record (EHR). In this paper we describe the benefits of an EHR, as they exist in the current IHC application and the ways in which we have sought to minimize obstacles to physician data entry. Currently, of 472 IHC employed physicians, 321 (68%) routinely enter some data directly into the EHR without coercion. Twenty-five percent (80/321) of the physicians use voice recognition for some data entry. Twelve of our 95 ambulatory clinics have voluntarily adopted measures to eliminate paper charts. Of the 212 physicians who entered data in 2004, sixty-nine physicians (22%) increased their level of data entry, while 12 (6%) decreased. We conclude that physicians will voluntarily adopt an EHR system, and will continue and even increase use after implementation barriers are addressed.

Advanced clinical information systems have been proposed to improve patient care in terms of safety, effectiveness, and efficiency. In order to be effective, such systems require detailed patient-specific clinical information in a form easily reviewed by clinicians. We have developed a patient summary worksheet for use in outpatient clinics, which presents a structured overview of patient health information. The worksheet provides patient demographic information, specific problems and conditions, the patient's current medication profile, laboratory test results pertinent to patient problems, and disease-specific or preventive care actionable advisories. Usage has grown from a few hundred to over 25,000 unique patients per month during a two-year period. Diabetic patients for whom the worksheet is accessed are significantly more likely to be in compliance with accepted testing regimens for glycosolated hemoglobin (OR 1.47, 95% CI 1.28, 1.61).

Prior to the implementation of Electronic Medical Record (EMR) web access for patients at a large integrated delivery systems, we surveyed physicians? attitudes. Our web based questionnaire revealed largely positive attitudes about access. The exceptions included abnormal reports, progress notes, and e-care. A factor analysis identified the group of physicians who didn?t view patients as partners felt most negative about the process.

To discuss the advantages and disadvantages of an interfaced approach to clinical information systems architecture. After many years of internally building almost all components of a hospital clinical information system (HELP) at Intermountain Health Care, we changed our architectural approach as we chose to encompass ambulatory as well as acute care. We now seek to interface applications from a variety of sources (including some that we build ourselves) to a clinical data repository that contains a longitudinal electronic patient record. We have a total of 820 instances of interfaces to 51 different applications. We process nearly 2 million transactions per day via our interface engine and feel that the reliability of the approach is acceptable. Interface costs constitute about four percent of our total information systems budget. The clinical database currently contains records for 1.45 m patients and the response time for a query is 0.19 sec. Based upon our experience with both integrated (monolithic) and interfaced approaches, we conclude that for those with the expertise and resources to do so, the interfaced approach offers an attractive alternative to systems provided by a single vendor. We expect the advantages of this approach to increase as the costs of interfaces are reduced in the future as standards for vocabulary and messaging become increasingly mature and functional.