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Computers in Medicine

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Computerized alerts and reminders improve primary care for HIV-infected patients

Computerized alerts and reminders to health care providers can significantly improve care of HIV-infected patients and speed adoption of practice guidelines for HIV care, according to a recent study. Charles Safran, M.D., and other researchers from Beth Israel Hospital and Harvard Medical School divided clinicians at the hospital's general medicine clinic into two groups. They delivered HIV practice recommendations via computer alerts and reminders to one group (the intervention group) and compared their care for HIV-infected patients with the care provided by a control group of doctors who did not receive alerts and reminders.

The 18-month study, which was conducted in 1992 and 1993, was supported in part by the Agency for Health Care Policy and Research (HS06288 and HS08749). The computer generated and transmitted 303 alerts for 191 patients in the intervention group and generated but did not transmit 388 alerts for 158 patients in the control group. Physicians receiving the alerts responded to the associated medical condition nearly five times faster than physicians who did not receive the alerts (11 vs. 52 days). Also, 1 month after the computer generated an alert, 29 percent more of the patients in the intervention group had received appropriate care.

For example, for patients in the intervention group in whom CD4 lymphocyte counts were suggested, the estimated median time until the test was performed was 24 days, compared with 70 days for patients in the control group. When a patient's CD4 count dropped below 500 and the intervention physician received the alert recommending antiviral therapy, the physician began therapy within a median 7 days, compared with 43 days for physicians in the control group. Finally, physicians who did not receive alerts took more than ten times as long as those who did (122 days vs. 11 days) to begin prophylaxis against Pneumocystis carinii pneumonia in patients whose CD4 count had fallen below 200.

Reminders, which appeared only when the physician looked at the patient's medical record online, also improved HIV care. The median time between generation of the reminder and the suggested action (for example, to send the patient for an eye exam) was 114 days in the intervention group and more than 500 days in the control group.

Details are in "Effects of a knowledge-based electronic patient record on adherence to practice guidelines," by Dr. Safran, David M. Rind, M.D., Roger B. Davis, Sc.D., and others, in the January-February 1996 issue of M.D. Computing 13(1), pp. 55-63.

National information superhighway should benefit health care

The White House's National Information Infrastructure (NII) initiative, which essentially links high-speed computers, broad-band networks, community networks, supporting software, and human interface nationwide, holds much promise for modern health care, according to J. Michael Fitzmaurice, Ph.D., Director of the Center for Information Technology, Agency for Health Care Policy and Research. He envisions that the NII will provide point-of-care information systems, clinical decision-support systems, access to the most current medical knowledge and experts for rural and inner-city practitioners and their patients, comparative information about health care plans and providers, public access to general health care information, information support of medical technology choices, and data to assess community public health status.

To achieve this vision, the United States will need to develop medical information standards for patient care data, develop and implement a system for unique personal identification, produce models to guide the flow of patient care data and information, enact Federal confidentiality and privacy laws to protect personal health data, experiment with repositories of health data to learn their benefits and drawbacks, undertake health care computer laboratory (test bed) development, and fund pilot tests and system evaluations.

Already, the United States and Europe have exchanged information via the Advanced Informatics in Medicine (AIM) program in the areas of telemedicine and computer-based patient records and cooperated in developing standards of clinical patient information. Two important reasons for these collaborative efforts in health care informatics, communications, and telemedicine are the expansion of business market opportunities and improved patient outcomes, according to Dr. Fitzmaurice. He concludes that although the government can provide substantial leadership and some funding, the development and application of health information systems will be predominantly a private-sector responsibility.

See "Information society challenges in the U.S.A." and "The American perspective for the future," two new book chapters by Dr. Fitzmaurice, which are published in Health in the New Communications Age, edited by M.F. Laires, M.J. Ladeira, and J.P. Christensen. Amsterdam, Netherlands: IOS Press, pp. 34-37 and 646-650, 1995.

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