Among Friends
e-Newsletter of the Friends of the National Library of Medicine (FNLM)
May 1, 2007 • Volume 2, Issue 5
An Early Electronic Medical Record System
As an intern at Boston City Hospital I spent most of my day gathering, organizing, and analyzing patient data, cross-checking new data against the old and what was expected, and adjusting treatments and testing accordingly. The days were consumed by hoards of little data gathering and checking tasks - work more like that of a bank clerk summing and double-checking deposits and receipts than that of Sherlock Holmes.
However, back then bank clerks had computer help. Physicians did not and, partly as a result, would sometimes fail at checking tasks and overlook an abnormality or preventive opportunity. Physicians need a computerized medical record to organize and watch their patients' records like a faithful sheep dog and call attention when it "sees" danger lurking.
When I arrived in Indianapolis at the Marion County General Hospital in 1972, I set out to develop an electronic medical record system that would accomplish three missions:
1. eliminate the logistic problems of the paper record: lost or unavailable, disorganized, or illegible
2. provide reminders to physicians about clinical situations that need action
3. provide query access across patients for research purposes
The project started with 32 patients in a diabetes clinic and then expanded to cover all patients. Early on, we developed a reminder system that could review the patients' records according to guidelines and remind physicians when it saw that patients needed specific tests, treatments, or immunizations. In a series of randomized trials beginning in 1973, we showed that such computer reminders increased the appropriate use of such interventions among eligible patients by 15 to 1,000 percent compared with the control state. The largest of these studies included more than 400 care providers, 1,000 reminder rules, 12,000 patients, and 50,000 visits. In late 1980, we developed one of the first physician order-entry systems and showed in a randomized trial that it significantly reduced costs compared with paper-based ordering.
By 2006 that system had evolved into the Indiana Network for Patient Care (INPC) a city-wide medical record system that carries records from all 15 Indianapolis hospitals (including more than 4 million distinct patients and a billion prescription records) and is growing at more than 80 million results per year. Today, when a patient checks into one of the participating hospitals for an emergency room, inpatient, or outpatient visit, the INPC gives providers in that facility access to the patient's full INPC record to facilitate their care. It further assists care by delivering reports electronically (labs, radiology, EKGs, general dictation) in a standard format to office practices - 1000 different offices and 3,100 different providers. It finds reportable cases for public health by reviewing the laboratory data it gets for evidence of tuberculosis, lead poisoning, etc. INPC facilitates a major share of the 3,000 human subject studies that are active at Indiana University Medical School, and it is the first and best example of a Regional Health Information Organization (RHIO) that the current administration is encouraging.
INPC developed and performed the first, and only, randomized controlled trial of a computer-based physician order-entry system compared to manual ordering, developed and disseminated the first clinical data exchange standard (ASTM 1238-88) which evolved into Health Level 7 (HL7), and is now used worldwide, and did the same with Logical Observations Identifiers Names and Codes (LOINC), a universal code system for identifying clinical variables in HL7 that has international use.
I was encouraged to come to the Lister Hill National Center for Biomedical Communications (LHNCBC) by Donald A.B. Lindberg, M.D. the director of the U.S. National Library of Medicine, whom I have long admired, to work at a national scale. The idea was that I could strengthen and continue the research underway at LHNCBC while adding a new research thread to develop software tools, policies, and standards that facilitate the capture, management, and analysis of patient data for clinical care, research, and public health.
The research opportunities for clinical databases are many. Many large, longitudinal studies are underway or planned on a national basis. The ability to aggregate electronic data collected during routine care in order to increase efficiency and quality, to speed clinical decisions and reduce waste as well as to draw inferences about drug safety and the cost benefit of treatments is increasing.
Numerous electronic databases containing enormous amounts of clinical data now exist. For example, the Medicare beneficiary database includes 7 billion records. The analysis of such large databases poses large technical challenges. The National Cancer Database (NCDB) carries 14 million cases. Registries for tracking patients with end-stage renal disease, cardiac catheterizations, bypass surgery, organ transplants, implanted pacemakers and defibrillators, and more offer other opportunities.
Much work and many kinds of efforts are required to develop the needed capabilities including data access tools that are reliable and easy to use by clinicians and patients, an automated and accurate de-identification process, and query and statistical analysis tools that can produce new discoveries without compromising privacy.
My interests include a number of these tools including data de-identification for preserving patient privacy, text understanding, statistical analysis, and linkage tools to improve availability and research utility of the clinical data contained in electronic medical records and long-term clinical databases.
NLM and FNLM News
The Board of Board of Regents of the NLM will meet on May 8th from 8:00 AM to 5:00 PM and 9th from 9:00 AM to 12:00 PM at the Library. For further information regarding the agenda, please contact Ms. Christine Ireland at 301-594-4929.
The Board of the FNLM will meet on May 9th at the Army Navy Club, 17th and I (Eye) Street, NW, Washington DC 9:00 AM to 12 PM, followed by lunch. For further information, contact Ms. Susan Corsini at 202-719-8094.
The Annual FNLM Fundraising Dinner will be held on May 8th, at the National Museum of Women in the Arts in Washington, DC from 6:15 to 9:30 PM. Receiving the Distinguished Medical Science Awards this year are Dr. Bernard Fisher (University of Pittsburgh) and Dr. Dennis Slamon (UCLA). In addition, the Michael E. DeBakey Award for Lifetime Achievement for Librarians will be given to Ms. Ada Seltzer as well as the Paul G. Rogers Public Service Award to Senator Edward Kennedy. For more information please contact Ms. Mirjam Krull at info@fnlm.org.
All members of the Medical Library Association and FNLM attending the annual meeting of MLA in Philadelphia on May 20th are invited to attend the FNLM reception at the Pennsylvania Academy of Fine Arts, 118-128 N. Broad St., Philadelphia, PA from 6:30 - 9:00 PM. Registration for attendees is available on the MLA registration meeting form at http://www.mlanet.org/am/am2007/pdf/pp_regform.pdf.
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You may also contact us directly at info@fnlm.org or write or call Ms. Susan Corsini, Executive Director of FNLM, at 2801 M Street, NW Washington, DC 20007, (202) 719-8094 for information about the FNLM organization and activities or the NIH MedlinePlus Magazine.
