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Home telecare is a promising method of improving access to care for rural and urban populations. It requires, however, that patients accept the installation and use of equipment in their home. How patients perceive home telecare may influence its acceptability and diffusion. We developed a questionnaire to assess patients' impressions of the risks and benefits of home telecare. A preliminary 20-item questionnaire was developed and tested on 32 subjects. It proved to be of acceptable reliability (Cronbach's alpha of 0.8) and validity, but three items appeared to be redundant. The final 17-item version was tested twice on 10 more subjects and was found to have high test-retest reliability. Most subjects showed an overall positive attitude towards home telecare and agreed it could improve their health. Many were concerned about being able to trust the equipment. The questionnaire can be used to investigate the acceptance of telemedicine and to improve the design of applications. [ABSTRACT FROM AUTHOR]

The prevalence of hypertension among the elderly is high. Recent multicenter studies have shown hypertension, especially isolated systolic hypertension, to be a risk factor and treatment to be elective, if individualized. In addition, the presence of multiple complicating conditions and the need for multiple medications in the elderly increases the required medical knowledge base necessary to appropriately determine antihypertensive therapy. To assist the primary provider, an expert system has been developed that provides advice on therapeutic decisions for elderly patients (greater than 65 years old and less than 85 years old). It takes into account such factors as age, sex, lifestyle, site of care, nutritional status, physiologic and pathophysiologic changes, co-existing diseases, multiple drug use, and prior antihypertensive drug exposure and response. The system user enters patients characteristics, disease states, risk factors, relevant laboratory values, and prior drug therapy. The system responds with a set of recommendations of appropriate therapy individualized for the specific patient. To further assist the process, relative costs of therapy are also included. The system, consisting of over 200 rules, is currently undergoing validation by a panel of cardiologists. It is implemented in IBM's Expert System Environment (ESE) on the IBM 4341. The authors wish to acknowledge the contribution of the ESE software by the IBM Corporation. [ABSTRACT FROM AUTHOR]

We developed a method of using the Clinically Aligned Pain Assessment (CAPA) measures to reconstruct the Numeric Rating System (NRS). We used an observational retrospective cohort study design with prospective validation using de-identified adult patient data derived from a major health system. Data between 2011-2017 were used for development and 2018-2020 for validation. All included patients had at least one NRS and CAPA measurement at the same time. An ordinal regression model was built with CAPA components to predict NRS scores. We identified 6,414 and 3,543 simultaneous NRS-CAPA pairs in the development and validation dataset, respectively. All CAPA components were significantly related to NRS, with RMSE of 1.938 and Somers' D of 0.803 on the development dataset, and RMSE of 2.1 and Somers' D of 0.74 when prospectively validated. Our model was capable of accurately reconstructing NRS based on CAPA and was exact when the NRS was [0,7].

Background: Cardiac Resynchronization Therapy (CRT) is an established pacing therapy for heart failure patients. The New York Heart Association (NYHA) class is often used as a measure of a patient's response to CRT. Identifying NYHA class for heart failure (HF) patients in an electronic health record (EHR) consistently, over time, can provide better understanding of the progression of heart failure and assessment of CRT response and effectiveness. Though NYHA is rarely stored in EHR structured data, such information is often documented in unstructured clinical notes., Methods: We accessed HF patients' data in a local EHR system and identified potential sources of NYHA, including local diagnosis codes, procedures, and clinical notes. We further investigated and compared the performances of rule-based versus machine learning-based natural language processing (NLP) methods to identify NYHA class from clinical notes., Results: Of the 36,276 patients with a diagnosis of HF or a CRT implant, 19.2% had NYHA class mentioned at least once in their EHR. While NYHA class existed in descriptive fields association with diagnosis codes (31%) or procedure codes (2%), the richest source of NYHA class was clinical notes (95%). A total of 6174 clinical notes were matched with hospital-specific custom NYHA class diagnosis codes. Machine learning-based methods outperformed a rule-based method. The best machine-learning method was a random forest with n-gram features (F-measure: 93.78%)., Conclusions: NYHA class is documented in different parts in EHR for HF patients and the documentation rate is lower than expected. NLP methods are a feasible way to extract NYHA class information from clinical notes.

Purpose: Hypertension (HTN) is significantly under-treated in stroke survivors. We examined usability and efficacy of a mHealth -based care model for improving post-stroke HTN control (Funding: AHRQ R21HS021794)., Methods: We used a RCT design. Planned study duration was 90 days. Intervention arm (IA) participants measured their BP daily using a smart phone and wireless BP monitor. This was transmitted automatically to the study database. Investigators (Physician + PharmD) made bi-weekly medication adjustments to achieve the BP goal. Control arm (CA) participants received a digital BP monitor and usual care. We examined Usability (measured with Marshfield System Usability Survey) and HTN control efficacy using an ITT (intent-to-treat) and as-treated (AT) analyses., Results: Fifty participants (IA = 28; CA = 22) completed the study. The Marshfield survey question, "I thought the system was easy to use" mean score was 4.6, (5 = strongly agree). Mean SBP declined significantly between enrollment and study completion in the IA. In ITT, IA SBP declined 9.88 mm, p = 0.005. In AT, IA SBP declined 10.81 mm, p = 0.0036. CA SBP decline was 5-6 mm Hg (not significant). In the ITT, baseline HTN control (SBP < 140 mm Hg) was 50% in IA and CA. At study completion, HTN was controlled in 82% (23/28) of IA and 64% (14/22) of CA (p = 0.14). In the AT, HTN was controlled in 89% (23/26) of IA and 58% (14/24) of CA, (p = 0.015)., Conclusion: A mHealth-based HTN care model had excellent usability and provided better HTN control than usual care in stroke survivors., Clinical Trial: gov: NCT01875094., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Cardiac Resynchronization Therapy (CRT) is an established pacing therapy for heart failure patients. The New York Heart Association (NYHA) classification is often used as a measure of a patient's response to CRT. Identifying NYHA class for heart failure patients in an electronic health record (EHR) consistently, over time, can provide better understanding of the progression of heart failure and assessment of CRT response and effectiveness. However, NYHA is rarely stored in EHR structured data such information is often documented in unstructured clinical notes. In this study, we thus investigated the use of natural language processing (NLP) methods to identify NYHA classification from clinical notes. We collected 6,174 clinical notes that were matched with hospital-specific custom NYHA class diagnosis codes. Machine-learning based methods performed similar with a rule-based method. The best machine-learning method, support vector machine with n-gram features, performed the best (93% F-measure). Further validation of the findings is required.

Objective The objective of this study was to demonstrate the utility of a healthcare data quality framework by using it to measure the impact of synthetic data quality issues on the validity of an eMeasure (CMS178—urinary catheter removal after surgery). Methods Data quality issues were artificially created by systematically degrading the underlying quality of EHR data using two methods: independent and correlated degradation. A linear model that describes the change in the events included in the eMeasure quantifies the impact of each data quality issue. Results Catheter duration had the most impact on the CMS178 eMeasure with every 1% reduction in data quality causing a 1.21% increase in the number of missing events. For birth date and admission type, every 1% reduction in data quality resulted in a 1% increase in missing events. Conclusion This research demonstrated that the impact of data quality issues can be quantified using a generalized process and that the CMS178 eMeasure, as currently defined, may not measure how well an organization is meeting the intended best practice goal. Secondary use of EHR data is warranted only if the data are of sufficient quality. The assessment approach described in this study demonstrates how the impact of data quality issues on an eMeasure can be quantified and the approach can be generalized for other data analysis tasks. Healthcare organizations can prioritize data quality improvement efforts to focus on the areas that will have the most impact on validity and assess whether the values that are reported should be trusted., Competing Interests: Conflict of Interest: None.

The purpose of this study was to create information models from flowsheet data using a data-driven consensus-based method. Electronic health records contain a large volume of data about patient assessments and interventions captured in flowsheets that measure the same "thing," but the names of these observations often differ, according to who performs documentation or the location of the service (eg, pulse rate in an intensive care, the emergency department, or a surgical unit documented by a nurse or therapist or captured by automated monitoring). Flowsheet data are challenging for secondary use because of the existence of multiple semantically equivalent measures representing the same concepts. Ten information models were created in this study: five related to quality measures (falls, pressure ulcers, venous thromboembolism, genitourinary system including catheter-associated urinary tract infection, and pain management) and five high-volume physiological systems: cardiac, gastrointestinal, musculoskeletal, respiratory, and expanded vital signs/anthropometrics. The value of the information models is that flowsheet data can be extracted and mapped for semantically comparable flowsheet measures from a clinical data repository regardless of the time frame, discipline, or setting in which documentation occurred. The 10 information models simplify the representation of the content in flowsheet data, reducing 1552 source measures to 557 concepts. The amount of representational reduction ranges from 3% for falls to 78% for the respiratory system. The information models provide a foundation for including nursing and interprofessional assessments and interventions in common data models, to support research within and across health systems.

Emerging issues of team-based care, precision medicine, and big data science underscore the need for health information technology (HIT) tools for integrating complex data in consistent ways to achieve the triple aims of improving patient outcomes, patient experience, and cost reductions. The purpose of this study was to demonstrate the feasibility of creating a hierarchical flowsheet ontology in i2b2 using data-derived information models and determine the underlying informatics and technical issues. This study is the first of its kind to use information models that aggregate team-based care across time, disciplines, and settings into 14 information models that were integrated into i2b2 in a hierarchical model. In the process of successfully creating a hierarchical ontology for flowsheet data in i2b2, we uncovered a variety of informatics and technical issues described in this paper.

Context: Underscreening and problematic repeat lead testing in children., Objective: Identify proportion of underscreening for elevated blood-lead levels in children. For children who receive a lead test, measure the level of problematic repeat lead tests, defined as those with a high probability of not meeting recommended guidelines for lead testing in children measured using a combination of patients' age, test type and sequencing, days between tests, and encounter diagnosis coding., Design: A population-based retrospective cross-sectional design., Setting: All health care services organizations in the state of Minnesota that delivered health services to the defined study population., Participants: The study population was a Medicaid cohort of 12 436 children aged 0 to 18 years observed over a 1-year period., Main Outcome Measures: Proportion of eligible children not receiving at least 1 lead test; proportion of problematic repeat lead tests., Results: Thirty-five percent of children who should have received at least 1 lead test (n = 1714) during the study period did not. A total of 1856 children had at least 1 lead test and 190 had 2 or more. Fifty percent (50%) of the repeat tests were identified as problematic, representing 5.1% of the lead tests performed. Repeat tests performed in different health systems than the systems where the initial tests were performed had 5.3 times greater odds (adjusted odds ratio: 5.3 [95% confidence interval, 2.8-9.9]) of being problematic., Conclusions: The current approach to delivering mandatory lead testing across the state Medicaid population does not ensure that children are appropriately tested and has potential inefficiencies in that testing when it does take place. Use of multiple health care systems is associated with increased potential inefficiencies. Future Medicaid accountable care agreements between the state Medicaid program and participating health systems should emphasize clear population accountability for test screenings to improve patients' safety. A central queryable health resource or health information exchange may enable this.

Repetition by clinicians of the same tests for a given patient is common. However, not all repeat tests are necessary for optimal care and can result in unnecessary hardship. Limited evidence suggests that an electronic health record may reduce redundant laboratory testing and imaging by making previous results accessible to physicians. The purpose of this study is to establish a baseline by characterizing repeat testing in a pediatric population and to identify significant risk factors associated with repeated tests, including the impact of using multiple health systems. A population-based retrospective cross-sectional design was used to examine initial and repeat test instances, defined as a second test following an initial test of the same type for the same patient. The study population consisted of 8760 children with 1-25 test claims over a 1-year period. The study setting included all health care service organizations in Minnesota that generated these claims. In all, 17.2% of tests met the definition of repeat test instances, with several risk factors associated with per patient repeat test levels. The incidence of repeat test instances per patient was significantly higher when patients received care from more than 1 health system (adjusted incidence rate ratio 1.4; 95% confidence interval: 1.3-1.5). Repeat test levels are significant in pediatric populations and potentially actionable. Interoperable health information technology may reduce the incidence of repeat test instances in pediatric populations by making prior test results readily accessible. (Population Health Management 2016;19:102-108).

Objective: The goal of this study is to apply an ontology based assessment process to electronic health record (EHR) data and determine its usefulness in characterizing data quality for calculating an example eMeasure (CMS178)., Methods: The process uses a data quality ontology that references separate data quality, domain and task ontologies to compute measures based on proportions of constraints that are satisfied. These quantities indicate how well the data conforms to the domain and how well it fits the task., Results: The process was performed on a de-identified 200,000 encounter sample from a hospital EHR. CodingConsistency was poor (44%) but DomainConsistency (97%) and TaskRelevance (95%) were very good. Improvements in the data quality Measures correlated with improvements in the eMeasure., Conclusion: This approach can encourage the development of new detailed Domain ontologies that can be reused for data quality purposes across different organizations' EHR data. Automating the data quality assessment process using this method can enable sharing of data quality metrics that may aid in making research results that use EHR data more transparent and reproducible.

The secondary use of EHR data for research is expected to improve health outcomes for patients, but the benefits will only be realized if the data in the EHR is of sufficient quality to support these uses. A data quality (DQ) ontology was developed to rigorously define concepts and enable automated computation of data quality measures. The healthcare data quality literature was mined for the important terms used to describe data quality concepts and harmonized into an ontology. Four high-level data quality dimensions ("correctness", "consistency", "completeness" and "currency") categorize 19 lower level measures. The ontology serves as an unambiguous vocabulary, which defines concepts more precisely than natural language; it provides a mechanism to automatically compute data quality measures; and is reusable across domains and use cases. A detailed example is presented to demonstrate its utility. The DQ ontology can make data validation more common and reproducible.

Health care data included in clinical data repositories (CDRs) are increasingly used for quality reporting, business analytics and research; however, extended clinical data from interprofessional practice are seldom included. With the increasing emphasis on care coordination across settings, CDRs need to include data from all clinicians and be harmonized to understand the impact of their collaborative efforts on patient safety, effectiveness and efficiency. This study characterizes the extended clinical data derived from EHR flowsheet data that is available in the University of Minnesota's CDR and describes a process for creating an ontology that organizes that data so that it is more useful and accessible to researchers. The process is illustrated using a pressure ulcer ontology and compares ease of finding concepts in i2b2 for different data organization approaches. The challenges of the manual process and difficulties combining similar concepts are discussed.

Background: EHR clinical document synthesis by clinicians may be time-consuming and error-prone due to the complex organization of narratives, excessive redundancy within documents, and, at times, inadvertent proliferation of data inconsistencies. Development of EHR systems that are easily adaptable to the user's work processes requires research into visualization techniques that can optimize information synthesis at the point of care., Objective: To evaluate the effect of a prototype visualization tool for clinically relevant new information on clinicians' synthesis of EHR clinical documents and to understand how the tool may support future designs of clinical document user interfaces., Methods: A mixed methods approach to analyze the impact of the visualization tool was used with a sample of eight medical interns as they synthesized EHR clinical documents to accomplish a set of four pre-formed clinical scenarios using a think-aloud protocol., Results: Differences in the missing (unretrieved) patient information (2.3±1.2 [with the visualization tool] vs. 6.8±1.2 [without the visualization tool], p = 0.08) and accurate inferences (1.3±0.3 vs 2.3±0.3, p = 0.09) were not statistically significant but suggest some improvement with the new information visualization tool. Despite the non-significant difference in total times to task completion (43±4 mins vs 36±4 mins, p = 0.35) we observed shorter times for two scenarios with the visualization tool, suggesting that the time-saving benefits may be more evident with certain clinical processes. Other observed effects of the tool include more intuitive navigation between patient details and increased efforts towards methodical synthesis of clinical documents., Conclusion: Our study provides some evidence that new information visualization in clinical notes may positively influence synthesis of patient information from EHR clinical documents. Our findings provide groundwork towards a more effective display of EHR clinical documents using advanced visualization applications.

Allina Hospitals & Clinics has implemented a fully integrated EHR. In the optimization of the EHR, they examined options for sharing the evidence base behind the content and presenting context sensitive answers to questions. After defining the evaluation criteria and options, they compared the options to the criteria. Allina has chosen to implement a database of clinician posed questions with concise answers coded to a patient and clinician context managed by an infobutton engine.

Advanced internet videoconferencing software and improving network connectivity have the potential to create high quality collaboration environments among clinical trial researchers and health care providers at primary care medical settings. However, site policy and support restrictions have limited the ability of medical researchers to benefit from these advances. Novel combinations of existing open source solutions hold promise for overcoming barriers to adoption. Simplified installation, configuration, and operation of videoconferencing will further assist medical research.

My Emergency Data (MED), a one-page clinical abstract, has been implemented as the first phase of a health information exchange (HIE) project across three healthcare systems. This study presents findings from one of a series of focus groups of emergency room (ER) providers' perceptions of MED. Barriers to using MED in the ER are identified and recommendations for improved utilization are provided.

A universal healthcare coverage program has been implemented in Thailand since 2001 and the Thailand Ministry of Public Health (MOPH) is restructuring its health information systems to support the management of this reform. The MOPH believes that health information technology (IT) is fundamental to the development of an effective health information system, and that users' adoption of health IT is one of the most important factors to the success of health IT implementation projects. However, there is no national data available regarding the penetration and adoption of health IT in Thai community health centers (CHCs). This cross sectional survey was designed to study the penetration and adoption of health IT in the country's community health centers. A random sample of 1,607 regionally stratified CHC's from a total of 9,806 CHCs was selected. With an 82% response rate, the data showed that people who worked in CHCs were currently heavy users of health IT. They exhibited high IT acceptance and positive attitudes toward using health IT. CHCs' staff was less resistant to adopt health IT than previously anticipated. These results are similar in all of the country's geographic regions. Health IT is pervasive in CHCs across the country and penetrates all regions.

The American Telemedicine Association (ATA) convened a panel of experts to generate a research agenda for the telemedicine community to further support and promote the long-term acceptance and use of telehealth. Three principles to guide research and four key areas within which research is greatly needed were identified. These four areas are technical, clinical, human factors and ergonomics, and economic analyses. It is the hope of the panel that the research recommendations put forth in this document will give investigators the inspiration, tools and goals to make this happen.

The Thailand universal health care coverage scheme was instituted in 2001 and The Thailand Ministry of Public Health (MOPH) is restructuring its information systems to support this reform. The MOPH anticipates developing computerized health information systems which can provide information for administration tasks and can improve both healthcare delivery and public health services. To achieve these target goals, knowledge about users and organizations is vital. The knowledge of how health center workers currently use information technology (IT), their knowledge of IT, and acceptance of IT are not only beneficial to policy makers but also to system designers and implementers. The primary objective of this study is to learn how health centers in Thailand use IT, the level of basic IT knowledge among their workers, and their acceptance of health IT. We surveyed a random cross sectional sample of 1,607 health centers representing the total of 9,806 in Thailand in 2005. With an 82% response rate, the preliminary results indicate that information technology usage is pervasive in health centers. The respondents showed a moderately high degree of health information technology acceptance with a modest level of basic IT knowledge. There were no differences in degrees of acceptance among the four geographic regions. The mean score of "intention to use IT" was 5.6 on a scale of 7 and the average basic IT knowledge score was 13 out of 20. These results suggests the possibility of project success if the national health center information system projects are developed and implemented.

Knowledge about socio-technical aspects of information technology (IT) is vital for the success of health IT projects. The Thailand health administration anticipates using health IT to support the recently implemented national universal health care system. However, the national knowledge associate with the socio-technical aspects of health IT has not been studied in Thailand. A survey instrument measuring Thai health center (HC) personnel's computer use, basic IT knowledge and HC computerized information system functionality needs was developed. The instrument reveals acceptable test-retest reliability and reasonable internal consistency of the measures. The future nation-wide demonstration study will benefit from this study.

User interface design is one of the most important parts of developing applications. Nowadays, a quality user interface must not only accommodate interaction between machines and users, but also needs to recognize the differences and provide functionalities for users from role-to-role or even individual-to-individual. With the web-based application of our Teledermatology consult system, the development environment provides us highly useful opportunities to create dynamic user interfaces, which lets us to gain greater access control and has the potential to increase efficiency of the system. We will describe the two models of user interfaces in our system: Role-based and Adaptive.

Ten patients in a home care study received virtual visits from nurses via analogue video-phones in their homes. They received standard home care services and two virtual visits per week. The visits were video-recorded and then reviewed. The study involved 10 patients and 10 nurses from one urban and three rural home care agencies. Six of the patients had congestive heart failure, three had chronic obstructive pulmonary disease and one required diabetes-related wound care. The average age of the patients was 78 years (SD 12). All but one lived in rural areas. One hundred and twenty-two virtual visits were reviewed for technical quality. Their mean duration was 21 min (range 5-60). The technical quality was given an average rating of 95% (range 57-100%). There were no technical problems in 78 visits (64%); in 10 cases (8%) there was difficulty establishing a connection. A content analysis of 30 of the visits identified 13 themes, such as assessing the patient's clinical status, promotion of compliance with medication and treatment, psychosocial issues, general informal talk and patient education. In general, the technical problems were minor and did not appear to interfere with care.

The study's objectives were to measure patients' perceptions of a telehomecare system before and after they have participated in it and identify the features of the system that patients perceived differently after experiencing it. The study setting was the TeleHomeCare Project, which uses videoconferencing and Internet equipment to enable interactions between patients and nurses. An instrument that measures perceptions of telehomecare was used. Patients viewed a videotape that demonstrates a "virtual home care visit" and filled out the questionnaire (pre-test). They were then randomly assigned to a control group receiving standard care or to an experimental group receiving videoconferencing and Internet access in addition to standard care. Both groups filled out the questionnaire when exiting the system (post-test). Paired t-tests were performed to compare total scores and responses to each of the items within the groups and an unpaired t-test was used to compare change of perceptions between groups. The control group consisted of 11 patients, and the experimental group included 17 patients. There was no statistically significant change of perception in the control group. The experimental group showed an overall more positive perception of the system after their experience (total score increase by 6.059, p < 0.0001), and the mean score difference was higher compared to the control group (mean 6.241, p < 0.0001). Elderly patients evaluated their telehomecare experience as being positive, and they felt more comfortable with the technology, believing that the nurse can understand their medical problem over the television. This suggests that telehomecare has the potential for wide acceptance among patients.

The study's objective was to analyze "virtual" home care visits that utilize telemedicine technology and to investigate the type and quality of interaction between provider and patient. The setting was the TeleHomeCare Project which provides TV-based videoconferencing. Patients are receiving standard home care services with an addition of virtual visits. 122 virtual visits were reviewed and a content analysis was performed for 30 of these. Time was apportioned among the following categories of communication: assessing the patient's clinical status, promoting compliance, addressing psychosocial issues, general informal talk, education, administrative issues, technical issues, assessing patient satisfaction and ensuring accessibility. The findings indicate that technology does not interfere with but rather enriches the care process. Although there are activities that cannot be conducted in virtual visits, they can address most of the important aspects of care delivery giving strength to the argument that they could in some cases substitute traditional visits.

This project provides educational support for students enrolled in a family practice clerkship by supplying PDA-based clinical references and tools to collect information about the patients they see and the seminars they attend. Each student is supplied with a Handspring Visor Deluxe to use during the clerkship. Supplied software includes a clinical reference (Five Minute Clinical Consult) and Lexidrugs drug reference and a medical calculator. The data collection software consists of a patient log for recording simple demographic and diagnostic information about each patient seen during the clerkship, a seminar evaluation module for recording student feedback about each didactic presentation during the course, and an evaluation form where they students supply their reactions to the use of the Visor. Despite encountering a number of problems, the devices appear to be beneficial tools. The applications provide useful references for students who do not have access to the resources of the University in their family medicine clerkship. They also provide an improved, though not perfect, means to capture data regarding patient encounters and course evaluations. However, the challenge remains to better integrate the PDA with the student s workflow in the clinic.

This article presents baseline work sampling data from an outpatient oncology clinic prior to an electronic medical record implementation. The physicians and medical office assistants spent 29% and 39% of their time, respectively, entering and retrieving information from medical records. The physicians and medical office assistants spent 43% and 17% of their time, respectively, on direct patient contact. Using scheduled outpatient counts to measure the productivity of the physicians and medical office assistants failed to capture 19% and 29% of their workload.

Objective: This study compares the costs of offering outpatient care to primarily orthopedic and dermatology patients via live, interactive telemedicine to the estimated costs of direct face-to-face care for the same patients., Materials and Methods: A simple, yet detailed methodology was used to evaluate the cost of adding telemedicine to a health care delivery system, using a "hub-and-spoke" model located in Minnesota. The costs and cost savings of telemedicine were evaluated from the perspectives of patients, providers, insurers, employers, and society as a whole. Sensitivity analysis was used to investigate the impact of various factors on the model., Results: The variable cost of a telemedicine referral was $144, versus an estimated face-to-face referral cost of $183. Reductions in patient travel costs and in lost employee productivity were the principal benefits of the system. The break-even point, where total costs equal total cost savings, equalled 1,449 consultations annually. Sensitivity analyses indicated that the breakeven point varies from a low of 152 telemedicine consultations for a "best case" scenario to no possible breakeven point for a "worst case" scenario., Conclusions: At the system's current level of 300 consultations per year, the telemedicine system is estimated to add $45,000 to society's costs of providing medical care for these patients. The additional cost is primarily due to personnel expenses and an increase in the volume of specialty care. Patients see specialists more often due to improved access to care and lower transportation costs. Providers bear the cost while patients and employers enjoy substantial savings.

This study was undertaken to clarify several aspects of the estimation of prevalence of three commonly use pediatric psychotropic agents, namely, methylphenidate, desipramine, and imipramine. The study aims are threefold: (1) to show the variability of drug prevalence by comparing estimates from three data sources; (2) to show the misleading impression that can be created by reporting drug prevalence estimates based on counts of prescriptions rather than persons; (3) to show the utility of gender-by-age-specific prevalence of drug use as a marker for diagnosis. Two data sources that yield population-based prescription estimates were available: 1991 Medicaid administrative claims data for prescriptions from a mid-Atlantic state and 1991 prescription records of the northwest region of Kaiser Permanente, a staff-model health maintenance organization (HMO). Another source of data consists of the 1991 National Ambulatory Medical Care Survey, which records medication information reported during physician office visits. Data analysis consists of quantitative estimates of (1) drug prevalence from each source; (2) the ratio of prescription claims to persons; and (3) the proportion of drug use according to age and gender. Methylphenidate and desipramine prevalence had a twofold greater use among state Medicaid enrollees compared with HMO enrollees. Average claims-to-person ratios of 5:1 suggest better accuracy using persons with medication rather than prescription counts. Gender-by-age-specific prevalence rates showed that 75% of the drug use for desipramine among those less than 15 years old was found among males, whereas 75% of the desipramine use among those 15 or older was found among females, suggesting its use for the treatment of attention deficit-hyperactivity disorder among young males and for depression among older females. The variability of community physician decision making in pediatric psychopharmacology is better understood by observing drug prevalence rates from different settings. National sampling efforts should be undertaken to verify regional and setting-specific prevalence findings and to learn the reasons for their fluctuation.

For several years, the American Society of Hospital Pharmacists (ASHP) has voiced concern about the impact of federally mandated changes on the pharmaceutical products marketplace. Since this marketplace is relatively inelastic, manipulating one segment in the interest of cost efficiencies is likely to result in price increases in other segments. That manipulation could come through such decisions as a "one-price" policy for pharmaceuticals, mandatory rebates for certain segments of the marketplace, or the elimination of discounts. The issue of cost-effective purchasing of prescription drugs and related supplies has recently come under increased scrutiny from the U.S. Congress, the Department of Health and Human Services, the General Accounting Office, and the Federal Trade Commission. In light of these and future activities, ASHP determined that there was a need to collect credible data on the potential impact of the termination of the Robinson-Patman Act's nonprofit institutional exemption, other discounts, or both on pharmaceutical expenditures in institutional health-care settings. The authors of this paper report the results and analysis of a 1990 mail survey conducted by ASHP and Concepts in Healthcare, Inc., to collect information on pharmaceutical purchasing and discounting procedures in community hospitals and selected nonhospital settings in the United States. Survey respondents reported that they would expect substantial increases in pharmaceutical expenditures if volume and nonprofit discounts were eliminated. Nonprofit hospitals expected a 24.4% increase in pharmaceutical expenditures in the wake of discount elimination, while for-profit institutions projected an 11.9% increase. Pharmaceutical expenditures of the study hospitals averaged $1.69 million per year; respondents estimated that this sum would increase by $390,000 (23.1%) if volume and nonprofit discounts were eliminated.

Objective: The objective of this article is to provide an overview of computer technology and an associated bibliography, emphasizing institutional-based healthcare applications and pharmacoinformatics., Data Sources: References were selected from the authors' files and from a computerized search over the last five years on computers in healthcare/medical informatics and in pharmacy., Study Selection: Articles selected for review and discussion were considered to be important contributions to the respective areas listed in the bibliography and representative of advancements in computer applications in healthcare and pharmacy., Data Synthesis: The computer has become an important support tool for healthcare professionals. Medical informatics and the discipline related to pharmacy, called pharmacoinformatics, have evolved from the cognitive underpinnings of medicine, pharmacy, and computer science. Recent developments in computer technology have resulted in computers that are fast, increasingly portable, and user friendly. Hospital information systems employ computers in various ways to deal with the vast amount of information used by various departments. Standards for electronic data exchange are being developed to increase the integration potential of these systems. Hospital pharmacists have used computers for drug distribution, financial analysis and inventory control, drug interaction detection, pharmacokinetic dosing, drug information, and drug therapy monitoring. Expert systems are being developed in several areas of drug therapy. Pharmacy educators have developed interactive courseware to help students learn problem-solving skills in the areas of calculations, therapeutics, and drug information., Conclusions: Pharmacists need to become more involved with applications of technology to pharmacy. Properly implemented, computers can provide more time for pharmacists to use their cognitive skills in the delivery of pharmaceutical care.

DUR is a process of problem detection and intervention designed to improve the quality and economy of drug prescribing. Retrospective DUR attempts to detect and address patterns of prescribing that might be indicative of inappropriate therapy. When the process is extended to a largely ambulatory population such as Medicaid beneficiaries, a number of complications are introduced due to the large numbers of patients and sparsity of data. In order to examine the impact of implementing a Medicaid DUR program, we developed a system that would apply screening criteria to prescription claims. It has been used to screen prescribing of groups of two antihypertensive drugs in the 1990 Maryland Medicaid population for 177,409 Medicaid eligible individuals. Potentially significant problems were detected with respect to dosing, duplication of therapeutic agents and drug interactions. The system represents, we believe, a significant improvement in the ability to detect and report prescribing decisions by increasing the specificity of the detection system. By the application of this system to a set of real-world data, we have demonstrated that it is feasible to implement such a system and derive results that are potentially useful in reducing the incidence of inappropriate physician decision-making.