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The vision of integrating information-from a variety of sources, into the way people work, to improve decisions and process-is one of the cornerstones of biomedical informatics. Thoughts on how this vision might be realized have evolved as improvements in information and communication technologies, together with discoveries in biomedical informatics, and have changed the art of the possible. This review identified three distinct generations of "integration" projects. First-generation projects create a database and use it for multiple purposes. Second-generation projects integrate by bringing information from various sources together through enterprise information architecture. Third-generation projects inter-relate disparate but accessible information sources to provide the appearance of integration. The review suggests that the ideas developed in the earlier generations have not been supplanted by ideas from subsequent generations. Instead, the ideas represent a continuum of progress along the three dimensions of workflow, structure, and extraction.

Informatics and information technology hold the promise of a consumer-centered health enterprise--one that provides quality care at a cost society is willing to pay; one where need-based, adaptive, competency-based learning results in cost-effectiveness of health education; one where team-based health and learning on demand, coupled with monitoring of process outcomes and network access to expertise, guarantee quality. The barriers to this promise are the professional guilds, the cross-subsidies that support the health enterprise of 1998, and the lack of respect for privacy. Collectively, the informatics community needs to develop a compelling vision that will galvanize the health community to action. If the health community does not step up to this challenge, consumers will take advantage of disintermediation. Empowered by the network, they will go outside the system into hands that meet their needs.

In March of 1997, the National Research Council (NRC) of the National Academy of Sciences issued the report, "For the Record: Protecting Electronic Health Information." In its report, the Council recommended both technical and organizational practices to protect electronic health information. At the time the report was issued, Vanderbilt University Medical Center was deeply immersed in the development of organizational practices consistent with the Council's recommendations. We agreed that the recommended technical and organizational practices are important for protecting other information types in addition to health information, and that they suggest appropriate practices for non-electronic information, as well. In this paper, we focus on our process for developing and implementing the seven organizational practices recommended for immediate implementation.

The changing economic environment in which our biomedical enterprises operate presents unparalleled opportunities to the profession of medical librarianship. Evidence-based medicine, patient empowerment, asynchronous learning networks, and research colaboratories each involve a new type of shared information, or access to information in new ways or by different people. These tasks are ones with which librarianship is directly involved. Librarians are therefore placed perfectly to provide new products and services. To position the library at the epicenter of the networked biomedical enterprise we must meet three challenges: We must align the library's business strategy with that of the larger enterprise. We must provide services in ways that will scale-up to enable new business strategies. We must measure the effectiveness of services in ways that document their role in supporting the enterprise.

Epidemiologic relatedness of Mycobacterium tuberculosis isolates from Arkansas residents diagnosed with tuberculosis in 1992-1993 was assessed using IS6110- and pTBN12-based restriction fragment length polymorphism (RFLP) and epidemiologic investigation. Patients with isolates having similar IS6110 patterns had medical records reviewed and were interviewed to identify epidemiologic links. Complete RFLP analyses were obtained for isolates of 235 patients; 78 (33%) matched the pattern of > or = 1 other isolate, forming 24 clusters. Epidemiologic connections were found for 33 (42%) of 78 patients in 11 clusters. Transmission of M. tuberculosis likely occurred many years in the past for 5 patients in 2 clusters. Of clusters based only on IS6110 analyses, those with > or = 6 IS6110 copies had both a significantly greater proportion of isolates that matched by pTBN12 analysis and patients with epidemiologic connections, indicating IS6110 patterns with few bands lack strain specificity. Secondary RFLP analysis increased specificity, but most clustered patients still did not appear to be epidemiologically related. RFLP clustering in rural areas may not represent recent transmission.

The Integrated Academic (Advanced) Information Management System (IAIMS) initiative emerged in the early 1980s to respond to trends in biomedical information, transfer and access, and to identify the implications for health sciences libraries. Three recurrent themes have emerged as being essential to the creation of IAIMs: changing the paradigm; redirecting expenditures to build reuseable infrastructure; and working across cultural boundaries. An IAIMS penetrates an organization in four stages: from creating awareness; through development of foundation infrastructure; through integration as an extra effort; to integration as a byproduct of organizational structure and information architecture. Extension of the IAIMS to support a regional area is a natural fifth stage that reapplies the processes of the first four stages and re-uses the infrastructure that has been built within the cooperating organizations. Area IAIMSs have the potential to transform biomedicine by enabling new paradigms for manpower development and publication of information.

The eighth annual workshop of the IAIMS Consortium was devoted to exploring how information technology might provide the tools to allow health care practices to compete in the new health care environment while maintaining independence. The options that were discussed included: optimizing care of the patient in the local setting; reducing practice overhead by improving efficiency and effectiveness; and finding innovative strategies for providing health care and new products.

Although tuberculosis is a disease known in antiquity, it was not distributed equally or simultaneously throughout the world. Recent genetic studies of the various species of mycobacteria give strong evidence of evolution of M. tuberculosis from saprophytic soil bacteria to M. bovis, which attacks a wide spectrum of lower animals, and then to M. tuberculosis, with the pathogenicity largely limited to humans. The great discrepancies in the time of arrival of this organism to diverse parts of the world, and in its ability to kill the young, account for significant differences in the emergence of innate resistance to tuberculosis in various populations. Innate resistance to particular infections are highly specific, and are derived from whatever scourge one's ancestors had to survive.

In 1992-1993, we investigated possible cross-contamination of Mycobacterium tuberculosis cultures as part of a study of tuberculosis in Arkansas by using DNA fingerprint analysis. Of patients whose isolates were matched, those for whom smears were negative and only one culture was positive were identified from laboratory records. Clinical, laboratory, DNA fingerprint, and epidemiological data were reviewed. Of 259 patients, nine (3.5%) were judged to be due to cross-contamination. None of these patients had a clinical course consistent with tuberculosis. All nine specimens were processed with another isolate with a matching DNA fingerprint, and epidemiological connections were not identified among any of the patients. To avoid erroneous diagnoses and unnecessary therapy and public health investigations, specimens from patients with tuberculosis whose smears are negative and only one culture is positive should be investigated for cross-contamination. An inconsistent clinical course and a DNA fingerprint that matches those of other culture-positive specimens processed concurrently, coupled with the lack of an epidemiological connection, suggest cross-contamination.

We describe the design and initial implementation of a notification sub-system, as a component of a modern information management architecture. The system, based on the publish-subscribe paradigm, provides a framework of event-based communications for the implementation of various important clinical applications including the notification of alerts and reminders with escalation algorithms, the reliable distribution of documents, and the implementation of intelligent patient-specific monitoring processes. The initial implementation of the system, providing the notification of the unit staff about new orders, indicates that the model is viable both in terms of functionality and ability to scale up.

Objective: Refine the understanding of the desirable skills for health sciences librarians as a basis for developing a training program model that reflects the fundamental changes in health care delivery and information technology., Design: A four-step needs assessment process: focus groups developed lists of desirable skills; the research team organized candidate skills into a taxonomy; a survey of a random sample of librarians and library users assessed perception of importance of individual skills; and the research team framed, as a unifying hypothesis, a training model., Survey Methods: The survey was distributed to random samples of 150 librarians, stratified by type of library, and 150 library users, stratified by type of use. A non-randomized sample was obtained by mounting the survey on a World Wide Web server. The survey instrument included 96 distinct skills organized into 13 categories. Respondents rated the importance of each skill on a Likert scale and provided a separate ranking by identifying the ten most important skills for the profession., Results: Among the participants, 51% of librarians and 36% of library users responded to the survey. All categories of skills were rated above the midpoint of priority on the Likert scale. All groups rated personality characteristics and skills as most important, with an understanding of the health sciences, education, and research being rated comparably to technical skills., Conclusions: Health sciences librarians need a new educational model that provides them with broad-based tools to discover new roles and new resources for acquiring individual skills as the need arises. A unifying training model would involve trainees in developing their learning plan in a way that promotes proactive inquiry and self-directed learning, and it would rotate the trainees through projects to provide skills and an understanding of end-user work processes.

Vanderbilt University Medical Center (VUMC) developed a model training program to prepare current and future health sciences librarians for roles that are integrated into the diverse fabric of the health care professions. As a complement to the traditional and theoretical aspects of a librarian's education, this mixture of supplemental coursework and intensive practical training emphasizes active management of information, problem-solving skills, learning in context, and direct participation in research, while providing the opportunity for advanced academic pursuits. The practical training will take place under the auspices of an established Integrated Advanced Information Management Systems (IAIMS) library that is fully integrated with the Health Center Information Management Unit and Academic Biomedical Informatics Unit. During the planning phase, investigators are analyzing the model's aims and requirements, concentrating on (a) refining the current understanding of the roles health sciences librarians occupy; (b) developing educational strategies that prepare librarians to fulfill expanded roles; and (c) planning for an evaluation process that will support iterative revision and refinement of the model.

Vanderbilt University Medical Center is implementing an Integrated Advanced Information Management System (IAIMS) using a fast-track approach. The elapsed time between start-up and completion of implementation will be 7.5 years. The Start-Up and Planning phases of the project are complete. The Implementation phase asks one question: How does an organization create an environment that redirects and coordinates a variety of individual activities so that they come together to provide an IAIMS? Four answers to this question are being tested. First, design resources to be "scalable"--i.e., capable of supporting enterprise-wide use. Second, provide information technology planning activities as ongoing core functions that direct local efforts. Third, design core infrastructure resources to be both reusable and expandable at the local level. Fourth, use milestones to measure progress toward selected endpoints to permit early refinement of plans and strategies.

Specific amplification of Mycobacterium tuberculosis DNA was investigated as an alternative to conventional microbiologic follow-up in 31 cases of smear- and culture-positive pulmonary tuberculosis. Strand displacement amplification (SDA) and the polymerase chain reaction (PCR) were applied to 438 sequential sputum specimens: 67 (15%) were positive by culture, 248 (57%) by SDA, and 231 (53%) by PCR (chi2=3.94, P=.05). Of 200 specimens collected >180 days after treatment started, none yielded positive cultures, while 50 (25%), representing 16 patients, were positive by both DNA assays. A weak correlation was demonstrated between DNA persistence in sputum and duration of culture positivity (r=0.45, P=.01), although no correlation was found with the radiographic extent of disease. The inability to distinguish live and dead organisms precludes DNA amplification from use in therapeutic monitoring. For this purpose, quantitative RNA assays are needed if such techniques are to supplant conventional microbiology.

Objective: To emphasize the differing infectious potentials of a patient with tuberculosis., Setting: Hospital ward and autopsy room., Design: An epidemiologic investigation of tuberculin skin test conversions in a clinical setting and during autopsy when results of tuberculin tests done before exposure were available for all participants., Measurements: Tuberculin skin test results after the discovery of tuberculosis exposure from a patient with unsuspected tuberculosis for comparison with the test results before exposure; culture of sputum and autopsy material for Mycobacterium tuberculosis; and DNA fingerprinting of organisms., Intervention: Preventive therapy for persons with skin test conversion., Results: None of the 40 skin test-negative health care workers caring for the patient for 3 weeks on an open medical ward showed a skin test conversion, even though they had not used respiratory precautions. By contrast, among personnel present during the 3-hour autopsy, the test results of all five nonreactors converted from negative to positive (mean reaction, 24 mm). Two of these persons had a positive sputum culture 8 weeks later. The DNA fingerprints of all three isolates were identical., Conclusions: A patient who did not transmit tuberculosis before death released a prodigious number of tubercle bacilli during autopsy.

Objective: To quantify the protection of previously infected persons from developing tuberculosis after intense exposure., Setting: 6 hospitals and 22 nursing homes in which heavy tuberculosis exposure had occurred., Measurements: Results of tuberculin skin tests before and after exposure and the development of tuberculosis among known reactors, both converters and nonconverters., Intervention: All converters were given preventive therapy with isoniazid as soon as they could be identified. Nonconverters and previously known reactors were not treated., Results: In 6 hospital outbreaks, largely aborted by prompt preventive therapy, 98 of 336 nonreactors (29%) showed skin test conversion, and, before therapy could be started, 19 (19% [95% CI, 12% to 29%]) had developed tuberculosis. No tuberculosis developed among the 238 nonconverters (0% [CI, 0% to 1.5%]) or the 76 known reactors who were not treated (0% [CI, 0.5% to 2%]). Tuberculosis developed in 5 of 209 known reactors (2.4% [CI, 0.8% to 5.5%]) in 22 nursing homes with heavy exposure, little more than 10 of 921 known reactors (1.1% [CI, 0.5% to 2%]) in 76 homes where there was no exposure (P = 0.17)., Conclusions: Healthy persons who remain nonreactive to tuberculin after heavy exposure have escaped infection and require no chemotherapy. However, if exposure is discovered immediately, it is wise to start preventive therapy in particularly heavily exposed non-reactors and discontinue it if the skin test result is still negative at 3 months. Persons who react after exposure fall into three groups: 1) converters, in whom the risk for tuberculosis warrants preventive chemotherapy, regardless of age; 2) reactors with no preexposure test results, who should be treated as converters; and 3) previously known reactors, in whom the risk for tuberculosis generally is too slight to warrant therapy. However, those who are younger than age 35 years, have human immunodeficiency virus infection, are receiving cancer chemotherapy or long-term corticosteroid therapy, or are otherwise immunocompromised should be considered for preventive therapy, regardless of the exposure.

Accurate, timely data are a necessary foundation for an effective healthcare information management system. Today's systems do not achieve their potential because they lack this essential ingredient. Technology can reduce the problem by making the data entry task easier, but a complete solution will require new strategies for system implementation and use. Functions must be implemented in a sequence that allows the initial functions to establish a data foundation for subsequent functions. Each atomic data item must be collected separately, with a consistent definition. Data capture strategies must permit data to be collected once, at the source. Finally, the data must be used, reused, and corrected by all members of the healthcare team.

This paper describes the deliverables framework developed by Vanderbilt University Medical Center (VUMC) in its IAIMS planning process. The key deliverables include: visions for the future; mission, goals, and objectives for the information management function; critical functions for IAIMS; categorized projects; priority recommendations; and a straw man project sequence reflecting dependencies. The paper also discusses how the plan will be used and how it interacts with direction-setting for the Medical Center.

Diagnostic difficulties arise when sputum smears are negative for acid-fast bacilli in tuberculin-positive patients with compatible symptoms and chest radiographs for tuberculosis. Many of these smear-negative patients yield positive cultures for M tuberculosis, whereas others remain culturally negative. Several studies have shown that many smear-negative/culture-negative patients will develop bacteriologically positive disease later. Often, physicians are unable to decide whether to initiate chemotherapy or to wait for the culture results. Also, if treatment is initiated in smear negative patients, what should be the drug regimen and duration of therapy. A positive smear signifies a very large bacterial population in the lung lesions whereas several negative smears suggest a smaller bacterial load. Such smear-negative cases do not require the same intensity and duration of treatment as smear-positive cases. Therapy should be initiated for tuberculosis after other causes for abnormal chest x-ray have been excluded. However, duration of therapy may be shortened in these cases. The British Medical Research Council (BMRC) study has shown that intensive treatment of smear-negative/culture-positive disease with streptomycin (SM), isoniazid (INH), rifampin (RIF), and pyrazinamide (PZA) for 4 months was uniformly successful. This regimen is routinely recommended in Hong Kong. Because primary drug resistance is low (< 3%) in Arkansas, we treated these cases with INH and RIF for 6 months with good results. This is now a routine drug regimen. For smear-negative/culture-negative cases, the BMRC study has shown that daily or thrice weekly treatment with SM, INH, RIF, and PZA for 4 months is effective.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct computer-based physician order entry has been the subject of debate for over 20 years. Many sites have implemented systems successfully. Others have failed outright or flirted with disaster, incurring substantial delays, cost overruns, and threatened work actions. The rationale for physician order entry includes process improvement, support of cost-conscious decision making, clinical decision support, and optimization of physicians' time. Barriers to physician order entry result from the changes required in practice patterns, roles within the care team, teaching patterns, and institutional policies. Key ingredients for successful implementation include: the system must be fast and easy to use, the user interface must behave consistently in all situations, the institution must have broad and committed involvement and direction by clinicians prior to implementation, the top leadership of the organization must be committed to the project, and a group of problem solvers and users must meet regularly to work out procedural issues. This article reviews the peer-reviewed scientific literature to present the current state of the art of computer-based physician order entry.

Careful study of medical informatics research and library-resource projects is necessary to increase the productivity of the research and development enterprise. Medical informatics research projects can present unique problems with respect to evaluation. It is not always possible to adapt directly the evaluation methods that are commonly employed in the natural and social sciences. Problems in evaluating medical informatics projects may be overcome by formulating system development work in terms of a testable hypothesis; subdividing complex projects into modules, each of which can be developed, tested and evaluated rigorously; and utilizing qualitative studies in situations where more definitive quantitative studies are impractical.

TB should be thought of as a slowly progressing worldwide epidemic. Initially it was a disease of lower mammals, and the etiologic agent probably preceded the development of man on earth. It became an uncommon endemic disease in man about the time man began to settle in villages and develop agriculture. Crowding in European cities, and later the industrial revolution in Europe, provided the necessary environmental conditions for the endemic disease to become epidemic. For the next 400 years, the disease was spread by European empire-building and colonization. It came late to sub-Saharan Africa and to the Pacific Islands, and still later to the highlands of New Guinea. The epidemic gradually wanes within a large population group as resistant individuals survive and reproduce. This natural resistance is reflected in the ability of the macrophage to control intracellular growth of the organism. The resistant host shows a chronic infection primarily affecting the lungs, whereas the highly susceptible host shows a rapidly fatal illness with generalized spread of disease to many organs. Survivors of the initial infection then show another type of resistance to reinfection that is based on sensitized T cells. When this system is only partially successful, the host becomes infectious and capable of spreading the infection widely. The study of the epidemiology of TB and the evaluation of various public health measures to prevent or contain the disease requires that the investigator have an understanding of the nature and duration of the TB epidemic in the particular population under study. This factor is a much greater determinant of the course of an epidemic than any public health measure that man can institute, just as the currents in a river can have a more powerful effect on the course of a canoe than the most vigorous paddler.