PaperChase: Computerized Bibliographic Retrieval to Answer Clinical Questions

PaperChase is a computerized bibliographic retrieval system that permits users without previous training to search the medical literature themselves at any time of the day or night. The database for PaperChase consists of approximately 425,000 references from 258 journals dating back eight years—nearly all the references shelved in the library of our hospital. In its first year of deployment, 1,032 users conducted 8,459 searches, during which they displayed 399,821 references and selected 97,869 of them for printing. The most common reason for using PaperChase is to answer a question of medical importance. As the results of the search are displayed, the titles of the retrieved references flash by; often one or more of them contain a declarative medical statement that answers the question of interest. To facilitate rapid review of these medical statements, we provided a new means to display references—just the titles, but four at a time. Examples are given which illustrate how users of PaperChase can find what they are looking for without consulting bound volumes.

PaperChase: Computerized Bibliographic Retrieval to Answer Clinical Questions

PaperChase is a computerized bibliographic retrieval system that permits users without previous training to search the medical literature themselves at any time of the day or night. The database for PaperChase consists of approximately 425,000 references from 258 journals dating back eight years—nearly all the references shelved in the library of our hospital. In its first year of deployment, 1,032 users conducted 8,459 searches, during which they displayed 399,821 references and selected 97,869 of them for printing.

The most common reason for using PaperChase is to answer a question of medical importance. As the results of the search are displayed, the titles of the retrieved references flash by; often one or more of them contain a declarative medical statement that answers the question of interest. To facilitate rapid review of these medical statements, we provided a new means to display references—just the titles, but four at a time. Examples are given which illustrate how users of PaperChase can find what they are looking for without consulting bound volumes.

Why good hospitals get bad computing

American Hospitals spend a lot of money for computing, but physicians and nurses are dissatisfied with the computing that they receive. No one is at fault. Rather, each person, acting in his or her best interest, unwittingly conspires to produce the unfavorable result. Until hospitals make major and fundamental changes in the way they purchase and manage computing, they will continue to spend large sums without commensurate return.

The CCC system in two teaching hospitals: a progress report

Computing systems developed by the Center for Clinical Computing (CCC) have been in operation in Beth Israel and Brigham and Women's hospitals for over 10 years. Designed to be of direct benefit to doctors, nurses, and other clinicians in the care of their patients, the CCC systems give the results of diagnostic studies immediately upon request; offer access to the medical literature: give advice, consultation, alerts, and reminders; assist in the day-to-day practice to medicine, and participate directly in the education of medical students and house officers. The CCC systems are extensively used, even by physicians who are under no obligation to use them. Studies have shown that the systems are well received and that they help clinicians improve the quality of patient care. In addition, the CCC systems have had a beneficial impact on the finances of the two hospitals, and they have cost less than what many hospitals spend for financial computing alone.

Conceptual mapping of user's queries to medical subject headings

This paper describes a way to map users' queries to relevant Medical Subject Headings (MeSH terms) used by the National Library of Medicine to index the biomedical literature. The method, called SENSE (SEarch with New SEmantics), transforms words and phrases in the users' queries into primary conceptual components and compares these components with those of the MeSH vocabulary. Similar to the way in which most numbers can be split into numerical factors and expressed as their product--for example, 42 can be expressed as 2*21, 6*7, 3*14, 2*3*7,--so most medical concepts can be split into "semantic factors" and expressed as their juxtaposition. Note that if we split 42 into its primary factors, the breakdown is unique: 2*3*7. Similarly, when we split medical concepts into their "primary semantic factors" the breakdown is also unique. For example, the MeSH term 'renovascular hypertension' can be split morphologically into reno, vascular, hyper, and tension--morphemes that can then be translated into their primary semantic factors--kidney, blood vessel, high, and pressure. By "factoring" each MeSH term in this way, and by similarly factoring the user's query, we can match query to MeSH term by searching for combinations of common factors. Unlike UMLS and other methods that match at the level of words or phrases, SENSE matches at the level of concepts; in this way, a wide variety of words and phrases that have the same meaning produce the same match. Now used in PaperChase, the method is surprisingly powerful in matching users' queries to Medical Subject Headings.

The federal role in the health information infrastructure: a debate of the pros and cons of government intervention

Some observers feel that the federal government should play a more active leadership role in educating the medical community and in coordinating and encouraging a more rapid and effective implementation of clinically relevant applications of wide-area networking. Other people argue that the private sector is recognizing the importance of these issues and will, when the market demands it, adopt and enhance the telecommunications systems that are needed to produce effective uses of the National Information Infrastructure (NII) by the healthcare community. This debate identifies five areas for possible government involvement: convening groups for the development of standards; providing funding for research and development; ensuring the equitable distribution of resources, particularly to places and people considered by private enterprise to provide low opportunities for profit; protecting rights of privacy, intellectual property, and security; and overcoming the jurisdictional barriers to cooperation, particularly when states offer conflicting regulations. Arguments against government involvement include the likely emergence of an adequate infrastructure under free market forces, the often stifling effect of regulation, and the need to avoid a common-and-control mentality in an infrastructure that is best promoted collaboratively.

Protection of confidentiality in the computer-based patient record

To evaluate the confidentiality of the patients' data in the electronic patient records designed by members of the Center for Clinical Computing in Boston, we examined the accessibility of the computer-stored medical records of two groups of patients at Boston's Beth Israel Hospital: celebrities, hospital employees, and their relatives (VIPs) and other patients (non-VIPs). We studied how often authorized clinicians gained access to computer-stored data on the two types of patients and whether look-up patterns differed if the data concerned a VIP. Our results suggest that the measures used to maintain data confidentiality at Beth Israel Hospital are adequate.

Effect of computer-based alerts on the treatment and outcomes of hospitalized patients

BACKGROUND

Hospital computing systems play an important part in the communication of clinical information to physicians. We sought to determine whether computer-based alerts for hospitalized patients can affect physicians' behavior and improve patients' outcomes.

METHODS

We performed a prospective time-series study to determine whether computerized alerts to physicians about rising creatinine levels in hospitalized patients receiving nephrotoxic or renally excreted medications led to more rapid adjustment or discontinuation of those medications, and to determine whether such alerts protected renal function.

RESULTS

Laboratory data were observed for 20,228 hospitalizations, with documentation of 1573 events (instances of rising creatinine levels during treatment with a nephrotoxic or renally excreted drug). During the intervention period, doses were adjusted or medications discontinued an average of 21.6 hours sooner after such an event (P < .0001). For patients receiving nephrotoxic medications during the intervention period, the relative risk of serious renal impairment was 0.45 (95% confidence interval, 0.22 to 0.94) as compared with the control period, and the mean serum creatinine level was 14.1 mumol/L (0.16 mg/dL) lower on day 3 (P < .01) and 25.6 mumol/L (0.29 mg/dL) lower on day 7 (P < .05) after an event. Forty-four percent of physicians who responded to a questionnaire said that the alerts had been helpful in the care of their patients, whereas 28% found them annoying. Sixty-five percent wished to continue receiving alerts.

CONCLUSIONS

Computer-based alerts regarding patients with rising creatinine levels affect physician behavior, prevent serious renal impairment, preserve renal function, and are accepted by clinicians.

Use of electronic mail in a teaching hospital

Electronic mail has been in use for almost 20 years at Boston's Beth Israel Hospital and is an integral part of the clinical information system. Through a study of usage patterns during a one-week period, we found that 1247 persons sent 7482 messages to 1302 different recipients. Each category of user (attending physician, house officer, nurse, etc.) sent the most e-mail to others of the same user category. Through an electronically administered questionnaire, we found that self-reported usage patterns had a high correlation (r = 0.6) with measured use. Sixty-six percent of respondents used e-mail daily or weekly, and 58% used it for issues of patient care; nearly all users found this useful for communicating about patient care issues. Ninety percent of respondents felt e-mail made their lives easier and 61% felt it had a humanizing influence on their lives. We conclude that the e-mail system is well-utilized by clinical personnel and felt to be useful in both patient care and nonpatient care situations.

Critique of an evaluation of software for searching MEDLINE

In a previous study, investigators at McMaster University compared 14 ways to search the MEDLINE database and concluded that the method that cost the least (the National Library of Medicine's ELHILL program) yielded the highest proportion of relevant articles, whereas the method that cost the most (PaperChase) yielded the least. There are serious defects in the study design that invalidate the authors' conclusions.

The effect of computer-based reminders on the management of hospitalized patients with worsening renal function

We performed a prospective time-series study to determine whether computerized reminders to physicians about rising creatinine levels in hospitalized patients receiving nephrotoxic and renally excreted medications led to more rapid adjustment or discontinuation of those medications, and to evaluate physician acceptance of computerized reminders. Laboratory data were followed on 10,076 patients over 13,703 admissions generating 1104 events of rising creatinine levels during treatment with nephrotoxic or renally excreted medications. During the intervention period, medications were adjusted or discontinued an average of 21.1 hours sooner (p less than 0.0001) after such an event occurred when compared with the control period. This effect of the reminders was strongest for patients receiving renally excreted and mildly nephrotoxic medications. Of physicians who responded to a computerized survey, 53% said that the reminders had been helpful in the care of their patients, while 31% felt that the reminders were annoying. Seventy-three percent wished to continue receiving computerized reminders. We conclude that computerized reminders are well-accepted in our hospital and have a strong effect on physician behavior.

Computer-based support for clinical decision making

Although computers are now commonly used for financial purposes in hospitals and physicians' offices, most physicians do not routinely use them in patient care. And in hospitals where laboratory data are provided on computer terminals, the displays are often difficult to use and programs that offer assistance in interpreting the data are usually unavailable. We have developed decision support programs that are widely used with the clinical computing system at our hospital. This paper describes the programs and how the clinicians use them.

ClinQuery: searching a large clinical database

We designed a user-friendly computer program that permits physicians to use clinical and demographic descriptors to search a hospital's clinical database for purposes of patient care, teaching, and research. For example, the user can identify all admissions in which diabetic ketoacidosis was diagnosed, the serum bicarbonate level was under 12 mmol/liter, and the length of stay exceeded 7 days. Once particular admissions have been identified, all data stored in the computerized record can be displayed. Authorized persons can also request the patient's complete medical record for further study. Over a 5-year period, 895 doctors, nurses, medical students, and hospital administrators used Clin-Query to search the clinical database of Boston's Beth Israel Hospital 3724 times. They displayed detailed information on 72,489 patients and requested the complete medical record 5477 times. Responses to a computer-based questionnaire indicated that 16% of the searches were performed for patient care, 38% for clinical research, 16% for teaching and education, 12% for hospital administration, and 18% for general exploration. We conclude that physicians and allied personnel will repeatedly examine and analyze aggregate clinical information when they are provided with the appropriate tools.

ClinQuery: a system for online searching of data in a teaching hospital

We designed a user-friendly computer program that permits physicians to search the clinical database of Boston's Beth Israel Hospital by clinical and demographic descriptors. For example, the user can identify all admissions in which diabetic ketoacidosis was diagnosed, the serum bicarbonate level was under 12 mmol/L, and the length of stay exceeded 7 days. Once particular admissions are identified, all data stored in the computerized record can be displayed. Authorized persons can also request the patient's complete medical record for further study. Over a 30-month period, 530 doctors, nurses, medical students, and administrators used the program to search the hospital's clinical database 1786 times. They displayed detailed information on 30,851 patients and requested the complete medical record 5319 times. In 1389 of the 1786 searches completed, the searcher responded to a computer-based questionnaire about motivation for the search. Responses indicated that 32% of the searches were for clinical research, 17% for patient care, 17% for teaching and education, 11% for hospital administration, and 12% for general exploration. In 58% of the searches, respondents indicated definite or probable success in finding the desired information. We conclude that physicians and allied personnel will repeatedly obtain, view, and analyze aggregate clinical information if they are provided with appropriate tools. We believe that such access to clinical information is an important resource for patient care, teaching, and clinical research.

Modeling the diagnosis of stroke at two hospitals

A comparison of five major categories of stroke in 651 patients revealed significant differences in the frequencies of diagnoses at the Beth Israel and Massachusetts General hospitals in Boston, Mass. (P less than 0.001 by chi-square test). To analyze these differences, we modeled the diagnostic process at each hospital with a Bayesian procedure and performed a crossover study in which each patient was rediagnosed by the model from the opposite hospital. The results indicate that the differences in the frequency of lacune and subarachnoid hemorrhage were associated with the patient population, whereas the differences in the frequency of embolism and atherothrombosis were associated with the diagnostic process. There was a marked difference in the use of arteriograms on the two stroke services, but no difference in morbidity or mortality. The modeling procedure described can be used to compare clinical processes when the allocation of patients is thought to be biased.

Role of computing in patient care in two hospitals

This report describes two hospital-wide clinical computing systems that assist physicians, nurses, medical students, and other clinicians in the care of their patients. From any of the video-display terminals located throughout the hospitals (666 at Beth Israel Hospital and 1250 at Brigham and Women's Hospital, both in Boston), clinicians can obtain results from the clinical laboratories; read diagnostic reports from the clinical departments; view lists of medications used during hospitalization and prescriptions filled in the outpatient pharmacy; request delivery of a patient's chart; request consultation on approaches to therapy; perform bibliographic retrieval of the MEDLINE database; and read, write, retract, edit, and forward electronic mail. During a one-week study period, 1737 clinicians at Beth Israel Hospital used one or more of the options in the clinical information system 58,757 times. During the same week, 2262 clinicians at Brigham and Women's Hospital used one or more of their options 89,101 times. The large amount of use by clinicians, who could, if they so desired, rely on printed reports or telephone calls to obtain their clinical information, suggests that a reliable, comprehensive, and easy-to-use computer system can contribute substantially to the quality of patient care.

Departmental and laboratory computing in two hospitals

This report describes the departmental and laboratory use of integrated, hospital-wide computing systems at Beth Israel and Brigham and Women's hospitals in Boston. The systems have an important role in the admitting, outpatient, and medical records departments; in the clinical departments (blood bank, cardiology, neurophysiology, pathology, radiology, and pharmacy); in the clinical laboratories; and at Brigham and Women's Hospital, in the financial departments. Information that is collected in the computers from these departments and laboratories is available for viewing by clinicians at terminals located throughout each hospital and is used in compiling charges for each patient's account. The programs are heavily used. During a one-week study period, 742 departmental and laboratory workers at Beth Israel Hospital filed or edited information in patients' computerized records 137,526 times. During the same week, 984 departmental and laboratory workers at Brigham and Women's Hospital filed or edited information 293,367 times. After the computing systems were introduced, the time required to collect unpaid bills decreased substantially at both hospitals.

Oral methoxsalen photochemotherapy for the treatment of psoriasis: a cooperative clinical trial. 1977

Extensive psoriasis in 1,308 patients has been treated two or three times a week with oral 8-methoxypsoralen followed by high intensity, long-wave ultraviolet light (PUVA). Excluding 169 patients still under early treatment, psoriasis cleared in 88% and failed to clear in 3%. One percent dropped out due to complications of treatment, and 8% for other reasons. The twice-a-week schedule was superior for patients with lighter skin types. Once a remission was induced, there was no difference in its maintenance when patients were treated once a week, once every other week, or once every third week. Each of these schedules was superior to no maintenance treatment. Immediate side effects of the 45,000 treatments administered in the first 18 months of this study were uncommon, temporary, and generally mild. No clinically significant changes in laboratory screening or eye examinations attributable to PUVA have been uncovered.

PaperChase: computerized bibliographical retrieval for the physician

PaperChase is a computer program that permits any physician or scientist to search the National Library of Medicine's MEDLINE data base of references to the biomedical literature. Written for the clinician rather than for the search librarian, PaperChase permits the user to search the entire MEDLINE collection of over 5,000,000 references published in 4,000 biomedical journals dating back to 1966. PaperChase is now available throughout the world to anyone who has a computer terminal or personal computer, and a modem. No special training is needed for a successful search. There is no user's manual. Users can search by title word, Medical Subject Heading, author's name, journal title, year of publication, language of publication, or any combination of the above. Users can read abstracts online, and they can request that a photocopy of the full text of any article be mailed to them.

Self-service computerized bibliographic retrieval: a comparison of Colleague and PaperChase, programs that search the MEDLINE data base

Colleague and PaperChase are the two most widely used computer systems designed specifically for clinicians and scientists who wish to search the National Library of Medicine's MEDLINE data base of references to the biomedical literature. The present study compares the performance of these two systems. Two matched groups of second-year medical students each received 3 hr of instruction, one group in Colleague, the other in PaperChase. Each student then attempted 10 test searches. The next day the groups were reversed, and each student attempted 5 additional searches. During 3 1/2 hr allocated for searching, users of Colleague attempted 64 test searches and retrieved 326 target references; users of PaperChase attempted 78 searches and retrieved 496. Users of Colleague took a mean of 2.2 min and spent a mean of $1.20 to find each target reference; users of PaperChase took 1.6 min and spent $0.92. We conclude that after limited training, medical students find more references faster and at lower cost with PaperChase than with Colleague.

Bringing the medical literature to physicians. Self-service computerized bibliographic retrieval

Seven years ago physicians at the Beth Israel Hospital in Boston began doing their own searches of the medical literature. They used PaperChase, a computer program written especially for end users rather than for search librarians. The data base was initially limited to the journals shelved in the library of the Beth Israel Hospital, but it has since been expanded to include the entire MEDLINE collection of the National Library of Medicine-nearly 5 million references published in 3,400 biomedical journals dating back to 1966.PaperChase is now available throughout the United States and Canada to anyone who has a computer terminal or personal computer and a modem. No special training is needed for a successful search and there is no user's manual. Users can search by title word, "medical subject heading," author's name, journal title, year of publication, language of publication or any combination of the above. They can read abstracts on line, and they can request that a photocopy of the full text of any article be mailed to them.

Clinical computing in a teaching hospital

This report describes a hospital-wide clinical computing system that permits physicians, nurses, medical students, and other health workers to retrieve data from the clinical laboratories; to look up reports from the departments of radiology and pathology; to look up demographic data and outpatient visits; to look up prescriptions filled in the outpatient pharmacy; to perform bibliographic retrieval of the MEDLINE data base; to read, write, retract, edit, and forward electronic mail; and to request delivery of a patient's chart. During a one-week study period, from 300 video display terminals located throughout the hospital, 818 patient care providers used a common registry of 539,000 patients to look up clinical and laboratory data 16,768 times; 477 other hospital workers used the patient registry 46,579 times. In a separate study of 586 health care providers, 470 (80 per cent) indicated that they used computer terminals "most of the time" to look up laboratory results; in contrast, 48 (8 per cent) preferred printed reports. Of 545 hospital workers, 440 (81 per cent) indicated that the computer terminals definitely or probably made their work more accurate, and 452 (83 per cent) indicated that terminals enabled them to work faster. The large amount of use by clinicians and their judgment that the computer has been so helpful to them suggests that a reliable, comprehensive, and easy-to-use computer system can contribute substantially to the quality of patient care.

Actinic degeneration in association with long-term use of PUVA

To determine the extent of clinical actinic damage that occurred in association with exposure to oral methoxsalen photochemotherapy (PUVA), dermatologists at 16 university centers assessed the wrinkling, telangiectasia, and altered skin markings on the buttocks and the dorsa of the hands among 1380 patients treated with PUVA. These changes are similar to those seen in skin that is chronically exposed to sunlight. After more than 5 years of prospective study, patients with psoriasis exposed to PUVA showed a significant dose-dependent increase in the prevalence of clinical actinic degeneration of the skin of the buttocks (p less than .05, F-test). The prevalence of moderate or severe change among those patients exposed to high doses of PUVA (more than 160 treatments) was low (11%). The degree of increased clinical actinic degeneration noted on the dorsa of the hands was also significantly related to total exposure to PUVA (p less than .05, F-test). Our findings indicate that long-term PUVA exposure is associated with an increase in clinical actinic degeneration of the skin. However, the magnitude of this increase is small and, after more than 5 years, is of limited clinical consequence to most patients.

Cutaneous squamous-cell carcinoma in patients treated with PUVA

A 5.7-year prospective study of 1380 patients treated for psoriasis with oral methoxsalen (8-methoxypsoralen) and ultraviolet A photochemotherapy (PUVA) revealed that after adjustment for exposures to ionizing radiation and topical tar preparations, the risk that cutaneous squamous-cell carcinoma would develop at least 22 months after the first exposure to PUVA was 12.8 times higher in patients exposed to a high dose than in those exposed to a low dose (95 per cent confidence interval, 5.8 to 28.5). No substantial dose-related increase was noted for basal-cell carcinoma. The dose-dependent risk of cutaneous squamous-cell carcinoma suggests that PUVA can act as an independent carcinogen. In our study, morbidity associated with these tumors has been limited, but further follow-up is needed. Meanwhile, patients treated with PUVA should be followed closely for the possible development of cutaneous squamous-cell carcinoma.