1
|
Celi LA, Zimolzak AJ, Stone DJ. Dynamic clinical data mining: search engine-based decision support. JMIR Med Inform 2014; 2:e13. [PMID: 25600664 PMCID: PMC4288074 DOI: 10.2196/medinform.3110] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 02/28/2014] [Accepted: 05/22/2014] [Indexed: 11/13/2022] Open
Abstract
The research world is undergoing a transformation into one in which data, on massive levels, is freely shared. In the clinical world, the capture of data on a consistent basis has only recently begun. We propose an operational vision for a digitally based care system that incorporates data-based clinical decision making. The system would aggregate individual patient electronic medical data in the course of care; query a universal, de-identified clinical database using modified search engine technology in real time; identify prior cases of sufficient similarity as to be instructive to the case at hand; and populate the individual patient's electronic medical record with pertinent decision support material such as suggested interventions and prognosis, based on prior outcomes. Every individual's course, including subsequent outcomes, would then further populate the population database to create a feedback loop to benefit the care of future patients.
Collapse
Affiliation(s)
- Leo Anthony Celi
- Harvard-MIT Division of Health Science and Technology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, United States.
| | | | | |
Collapse
|
2
|
Fine AM, Nizet V, Mandl KD. Participatory medicine: A home score for streptococcal pharyngitis enabled by real-time biosurveillance: a cohort study. Ann Intern Med 2013; 159:577-83. [PMID: 24189592 PMCID: PMC3953456 DOI: 10.7326/0003-4819-159-9-201311050-00003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Consensus guidelines recommend against testing or treating adults at low risk for group A streptococcal (GAS) pharyngitis. OBJECTIVE To help patients decide when to visit a clinician for the evaluation of sore throat. DESIGN Retrospective cohort study. SETTING A national chain of retail health clinics. PATIENTS 71 776 patients aged 15 years or older with pharyngitis who visited a clinic from September 2006 to December 2008. MEASUREMENTS The authors created a score using information from patient-reported clinical variables plus the incidence of local disease and compared it with the Centor score and other traditional scores that require clinician-elicited signs. RESULTS If patients aged 15 years or older with sore throat did not visit a clinician when the new score estimated the likelihood of GAS pharyngitis to be less than 10% instead of having clinicians manage their symptoms following guidelines that use the Centor score, 230 000 visits would be avoided in the United States each year and 8500 patients with GAS pharyngitis who would have received antibiotics would not be treated with them. LIMITATION Real-time information about the local incidence of GAS pharyngitis, which is necessary to calculate the new score, is not currently available. CONCLUSION A patient-driven approach to pharyngitis diagnosis that uses this new score could save hundreds of thousands of visits annually by identifying patients at home who are unlikely to require testing or treatment. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention and the National Library of Medicine, National Institutes of Health.
Collapse
|
3
|
Kulik DM, Uleryk EM, Maguire JL. Does This Child Have Bacterial Meningitis? A Systematic Review of Clinical Prediction Rules for Children with Suspected Bacterial Meningitis. J Emerg Med 2013; 45:508-19. [DOI: 10.1016/j.jemermed.2013.03.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 10/03/2012] [Accepted: 03/15/2013] [Indexed: 10/26/2022]
|
4
|
Walsh P, Overmyer C, Hancock C, Heffner J, Walker N, Nguyen T, Shanholtzer L, Caldera E, Pusavat J, Mordechai E, Adelson ME, Iacono KT. Is the interpretation of rapid antigen testing for respiratory syncytial virus as simple as positive or negative? Emerg Med J 2013; 31:153-9. [PMID: 23964062 DOI: 10.1136/emermed-2013-202729] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To measure the performance characteristics of an immunochromatographic rapid antigen test for respiratory syncytial virus (RSV) and determine how its interpretation should be contextualised in patients presenting to the emergency department (ED) with bronchiolitis. DESIGN Diagnostic accuracy study of a rapid RSV test. SETTING County hospital ED. INTERVENTION We took paired nasal samples from consecutively enrolled infants with bronchiolitis and tested them with a rapid immunochromatographic antigen test and reverse transcriptase PCR gold standard. OUTCOME MEASURES Sensitivity, specificity, the effect of point prevalence, clinical findings and overall context on predictive values. We used these to construct a graphical contextual model to show how the results of RSV antigen tests from infants presenting within 24 h should influence interpretation of subsequent antigen tests. RESULTS We analysed 607 patients. The sensitivity and specificity for immunochromatographic testing was 79.4% (95% CI 73.9% to 84.2%) and 67.1% (95% CI 61.9% to 72%) respectively. We found little evidence of spectrum bias. In our contextual model the best predictor of a positive RT-PCR test was a positive antigen test OR 5.47 (95% CI 3.65 to 8.18) and the number of other infants having positive tests within 24 h OR 1.48 (95% CI 1.26 to 1.72) per infant. Increasing numbers presenting to the ED with bronchiolitis in a given day increases the probability of RSV infection. CONCLUSIONS The RSV antigen test we examined had modest performance characteristics. The results of the antigen test should be interpreted in the context of the results of previous tests.
Collapse
Affiliation(s)
- Paul Walsh
- Department of Emergency Medicine, University of California Davis, , Sacramento, California, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Friedman DJ, Parrish RG, Ross DA. Electronic health records and US public health: current realities and future promise. Am J Public Health 2013; 103:1560-7. [PMID: 23865646 DOI: 10.2105/ajph.2013.301220] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Electronic health records (EHRs) could contribute to improving population health in the United States. Realizing this potential will require understanding what EHRs can realistically offer to efforts to improve population health, the requirements for obtaining useful information from EHRs, and a plan for addressing these requirements. Potential contributions of EHRs to improving population health include better understanding of the level and distribution of disease, function, and well-being within populations. Requirements are improved population coverage of EHRs, standardized EHR content and reporting methods, and adequate legal authority for using EHRs, particularly for population health. A collaborative national effort to address the most pressing prerequisites for and barriers to the use of EHRs for improving population health is needed to realize the EHR's potential.
Collapse
|
6
|
Fine AM, Nizet V, Mandl KD. Improved diagnostic accuracy of group A streptococcal pharyngitis with use of real-time biosurveillance. Ann Intern Med 2011; 155:345-52. [PMID: 21930851 PMCID: PMC3651845 DOI: 10.7326/0003-4819-155-6-201109200-00002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Clinical prediction rules do not incorporate real-time incidence data to adjust estimates of disease risk in symptomatic patients. OBJECTIVE To measure the value of integrating local incidence data into a clinical decision rule for diagnosing group A streptococcal (GAS) pharyngitis in patients aged 15 years or older. DESIGN Retrospective analysis of clinical and biosurveillance predictors of GAS pharyngitis. SETTING Large U.S.-based retail health chain. PATIENTS 82 062 patient visits for pharyngitis. MEASUREMENTS Accuracy of the Centor score was compared with that of a biosurveillance-responsive score, which was essentially an adjusted Centor score based on real-time GAS pharyngitis information from the 14 days before a patient's visit: the recent local proportion positive (RLPP). RESULTS Increased RLPP correlated with the likelihood of GAS pharyngitis (r(2) = 0.79; P < 0.001). Local incidence data enhanced diagnostic models. For example, when the RLPP was greater than 0.30, managing patients with Centor scores of 1 as if the scores were 2 would identify 62, 537 previously missed patients annually while misclassifying 18, 446 patients without GAS pharyngitis. Decreasing the score of patients with Centor values of 3 by 1 point for an RLPP less than 0.20 would spare unnecessary antibiotics for 166, 616 patients while missing 18, 812 true-positive cases. LIMITATIONS Analyses were conducted retrospectively. Real-time regional data on GAS pharyngitis are generally not yet available to clinicians. CONCLUSION Incorporating live biosurveillance data into clinical guidelines for GAS pharyngitis and other communicable diseases should be considered for reducing missed cases when the contemporaneous incidence is elevated and for sparing unnecessary antibiotics when the contemporaneous incidence is low. Delivering epidemiologic data to the point of care will enable the use of real-time pretest probabilities in medical decision making.
Collapse
Affiliation(s)
- Andrew M. Fine
- Division of Emergency Medicine, Department of Medicine, Children’s Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston MA
| | - Victor Nizet
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California
| | - Kenneth D. Mandl
- Division of Emergency Medicine, Department of Medicine, Children’s Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston MA
- Children’s Hospital Informatics Program, Harvard-MIT Health Sciences and Technology, Boston, MA
- Center for Biomedical Informatics, Harvard Medical School, Boston, MA
| |
Collapse
|
7
|
Maguire JL, Kulik DM, Laupacis A, Kuppermann N, Uleryk EM, Parkin PC. Clinical prediction rules for children: a systematic review. Pediatrics 2011; 128:e666-77. [PMID: 21859912 DOI: 10.1542/peds.2011-0043] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT The degree to which clinical prediction rules (CPRs) for children meet published standards is unclear. OBJECTIVE To systematically review the quality, performance, and validation of published CPRs for children, compare them with adult CPRs, and suggest pediatric-specific changes to CPR methodology. METHODS Medline was searched from 1950 to 2011. Studies were selected if they included the development of a CPR involving children younger than 18 years. Two investigators assessed study quality, rule performance, and rule validation as methodologic standards. RESULTS Of 7298 titles and abstracts assessed, 137 eligible studies were identified. They describe the development of 101 CPRs addressing 36 pediatric conditions. Quality standards met in fewer than half of the studies were blind assessment of predictors (47%), reproducibility of predictors (18%), blind assessment of outcomes (42%), adequate follow-up of outcomes (36%), adequate power (43%), adequate reporting of results (49%), and 95% confidence intervals reported (36%). For rule performance, 48% had a sensitivity greater than 0.95, and 43% had a negative likelihood ratio less than 0.1. For rule validation, 76% had no validation, 17% had narrow validation, 8% had broad validation, and none had impact analysis performed. Compared with CPRs for adult health conditions, quality and rule validation seem to be lower. CONCLUSIONS Many CPRs have been derived for children, but few have been validated. Relative to adult CPRs, several quality indicators demonstrated weaknesses. Existing performance standards may prove elusive for CPRs that involve children. CPRs for children that are more assistive and less directive and include patients' values and preferences in decision-making may be helpful.
Collapse
Affiliation(s)
- Jonathon L Maguire
- Department of Pediatrics, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|
8
|
Fine AM, Brownstein JS, Nigrovic LE, Kimia AA, Olson KL, Thompson AD, Mandl KD. Integrating spatial epidemiology into a decision model for evaluation of facial palsy in children. ACTA ACUST UNITED AC 2011; 165:61-7. [PMID: 21199982 DOI: 10.1001/archpediatrics.2010.250] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To develop a novel diagnostic algorithm for Lyme disease among children with facial palsy by integrating public health surveillance data with traditional clinical predictors. DESIGN Retrospective cohort study. SETTING Children's Hospital Boston emergency department, 1995-2007. PATIENTS Two hundred sixty-four children (aged <20 years) with peripheral facial palsy who were evaluated for Lyme disease. MAIN OUTCOME MEASURES Multivariate regression was used to identify independent clinical and epidemiologic predictors of Lyme disease facial palsy. RESULTS Lyme diagnosis was positive in 65% of children from high-risk counties in Massachusetts during Lyme disease season compared with 5% of those without both geographic and seasonal risk factors. Among patients with both seasonal and geographic risk factors, 80% with 1 clinical risk factor (fever or headache) and 100% with 2 clinical factors had Lyme disease. Factors independently associated with Lyme disease facial palsy were development from June to November (odds ratio, 25.4; 95% confidence interval, 8.3-113.4), residence in a county where the most recent 3-year average Lyme disease incidence exceeded 4 cases per 100,000 (18.4; 6.5-68.5), fever (3.9; 1.5-11.0), and headache (2.7; 1.3-5.8). Clinical experts correctly treated 68 of 94 patients (72%) with Lyme disease facial palsy, but a tool incorporating geographic and seasonal risk identified all 94 cases. CONCLUSIONS Most physicians intuitively integrate geographic information into Lyme disease management, but we demonstrate quantitatively how formal use of geographically based incidence in a clinical algorithm improves diagnostic accuracy. These findings demonstrate potential for improved outcomes from investments in health information technology that foster bidirectional communication between public health and clinical settings.
Collapse
Affiliation(s)
- Andrew M Fine
- Division of Emergency Medicine, Children's Hospital Boston, Boston, MA 02115, USA.
| | | | | | | | | | | | | |
Collapse
|
9
|
Lurio J, Morrison FP, Pichardo M, Berg R, Buck MD, Wu W, Kitson K, Mostashari F, Calman N. Using electronic health record alerts to provide public health situational awareness to clinicians. J Am Med Inform Assoc 2010; 17:217-9. [PMID: 20190067 DOI: 10.1136/jamia.2009.000539] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Alerting providers to public health situations requires timeliness and context-relevance, both lacking in current systems. Incorporating decision support tools into electronic health records may provide a way to deploy public health alerts to clinicians at the point of care. A timely process for responding to Health Alert Network messages sent by the New York City Department of Health and Mental Hygiene was developed by a network of community health centers. Alerts with order sets and recommended actions were created to notify primary care providers of local disease outbreaks. The process, effect, and lessons learned from alerts for Legionella, toxogenic E coli, and measles outbreaks are described. Electronic alerts have the potential to improve management of diseases during an outbreak, including appropriate laboratory testing, management guidance, and diagnostic assistance as well as to enhance bi-directional data exchange between clinical and public health organizations.
Collapse
Affiliation(s)
- Joseph Lurio
- Institute for Family Health, New York, NY 10032, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Fine AM, Reis BY, Nigrovic LE, Goldmann DA, Laporte TN, Olson KL, Mandl KD. Use of population health data to refine diagnostic decision-making for pertussis. J Am Med Inform Assoc 2010; 17:85-90. [PMID: 20064807 DOI: 10.1197/jamia.m3061] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To improve identification of pertussis cases by developing a decision model that incorporates recent, local, population-level disease incidence. DESIGN Retrospective cohort analysis of 443 infants tested for pertussis (2003-7). MEASUREMENTS Three models (based on clinical data only, local disease incidence only, and a combination of clinical data and local disease incidence) to predict pertussis positivity were created with demographic, historical, physical exam, and state-wide pertussis data. Models were compared using sensitivity, specificity, area under the receiver-operating characteristics (ROC) curve (AUC), and related metrics. RESULTS The model using only clinical data included cyanosis, cough for 1 week, and absence of fever, and was 89% sensitive (95% CI 79 to 99), 27% specific (95% CI 22 to 32) with an area under the ROC curve of 0.80. The model using only local incidence data performed best when the proportion positive of pertussis cultures in the region exceeded 10% in the 8-14 days prior to the infant's associated visit, achieving 13% sensitivity, 53% specificity, and AUC 0.65. The combined model, built with patient-derived variables and local incidence data, included cyanosis, cough for 1 week, and the variable indicating that the proportion positive of pertussis cultures in the region exceeded 10% 8-14 days prior to the infant's associated visit. This model was 100% sensitive (p<0.04, 95% CI 92 to 100), 38% specific (p<0.001, 95% CI 33 to 43), with AUC 0.82. CONCLUSIONS Incorporating recent, local population-level disease incidence improved the ability of a decision model to correctly identify infants with pertussis. Our findings support fostering bidirectional exchange between public health and clinical practice, and validate a method for integrating large-scale public health datasets with rich clinical data to improve decision-making and public health.
Collapse
Affiliation(s)
- Andrew M Fine
- Division of Emergency Medicine, Children's Hospital Boston and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115, USA.
| | | | | | | | | | | | | |
Collapse
|
11
|
Cerebrospinal fluid pleocytosis in children in the era of bacterial conjugate vaccines: distinguishing the child with bacterial and aseptic meningitis. Pediatr Emerg Care 2009; 25:112-7; quiz 118-20. [PMID: 19225382 DOI: 10.1097/pec.0b013e318196faeb] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although bacterial meningitis remains an important cause of childhood morbidity and mortality, the incidence of bacterial meningitis has greatly decreased with the advent of polysaccharide-protein conjugate vaccines in the past 2 decades. Most children with cerebrospinal fluid pleocytosis have aseptic rather than bacterial meningitis, raising the possibility that some patients may be managed as outpatients. In this article, we review the changing epidemiology of bacterial meningitis as well as the available clinical decision rules that may assist the clinician in distinguishing aseptic from bacterial meningitis in patients with cerebrospinal fluid pleocytosis.
Collapse
|
12
|
Gundlapalli AV, Tang H, Tonnierre C, Stoddard G, Rolfs RT, Evans RS, Samore MH. Validity of electronic medical record-based rules for the early detection of meningitis and encephalitis. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2007; 2007:299-303. [PMID: 18693846 PMCID: PMC2655809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 07/20/2007] [Accepted: 10/11/2007] [Indexed: 05/26/2023]
Abstract
Diseases of the central nervous system (CNS) such as meningitis or encephalitis may represent events of public health interest due to emerging infections and/or NIH/CDC Category B priority pathogens. Apart from influencing treatment and management of the index case, some diagnoses such as meningococcal meningitis warrant an immediate public health response. Others such as West Nile Virus may require public education and vector control. Thus early detection of CNS syndromes is of benefit to patients, providers and public health. While computer-based surveillance methods have been used with success in the early detection of respiratory syndromes, there is little data on their use in CNS syndromes. This study analyzed the validity of a hospital emergency department computer-based surveillance system in the early detection of meningitis and encephalitis and determined the test characteristics of selected computer-based rules.
Collapse
Affiliation(s)
- Adi V Gundlapalli
- Department of Internal Medicine, University of Utah School of Medicine, USA
| | | | | | | | | | | | | |
Collapse
|
13
|
Kukafka R, Ancker JS, Chan C, Chelico J, Khan S, Mortoti S, Natarajan K, Presley K, Stephens K. Redesigning electronic health record systems to support public health. J Biomed Inform 2007; 40:398-409. [PMID: 17632039 DOI: 10.1016/j.jbi.2007.07.001] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Revised: 06/15/2007] [Accepted: 07/02/2007] [Indexed: 11/25/2022]
Abstract
Current electronic health record systems are primarily clinical in focus, designed to provide patient-level data and provider-level decision support. Adapting EHR systems to serve public health needs provides the possibility of enormous advances for public health practice and policy. In this review, we evaluate EHR functionality and map it to the three core functions of public health: assessment, policy development, and assurance. In doing so, we identify and discuss important design, implementation, and methodological issues with current systems. For example, in order to support public health's traditional focus on preventive health and socio-behavioral factors, EHR data models would need to be expanded to incorporate environmental, psychosocial, and other non-medical data elements, and workflow would have to be examined to determine the optimal way of collecting these data. We also argue that redesigning EHR systems to support public health offers benefits not only to the public health system but also to consumers, health-care institutions, and individual providers.
Collapse
Affiliation(s)
- Rita Kukafka
- Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, 622 W. 168th Street, Vanderbilt Clinic VC5, New York, NY 10032, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|