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Approaches to the development of information systems in large health care institutions range from prototyping to conventional development of large scale production systems. This paper discusses the development of the SignOut System at Mount Sinai Medical Center, which was designed in 1997 to capture vital resident information. Local need quickly outstripped proposed delays for building a production system and a prototype system quickly became a production system. By the end of 2002 the New SignOut System was built to create an integrated application that was a true production system. In this paper we discuss the design and implementation issues in moving from a prototype to a production system. The production system had a number of advantages, including increased organizational visibility, integration into enterprise resource planning and full time staff for support. However, the prototype allowed for more rapid design and subsequent changes, less training, and equal to or superior help desk support. It is argued that healthcare IT systems may need characteristics of both prototype and production system development to rapidly meet the changing and different needs of healthcare user populations.

Objective: To assess physician–patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. Design: An exploratory, observational study involving analysis of videotaped physician–patient encounters, questionnaires, and medical-record reviews. Setting: General internal medicine practice at an academic medical center. Participants: Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). Main Outcome Measures: Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. Results: Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patient's agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patient's life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. Summary: An EMR system may enhance the ability of physicians to complete informationintensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified.

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.

Linking medications with their indications is important for clinical care and research. We have recently developed a freely-available, computable medication-indication resource, called MEDI, which links RxNorm medications to indications mapped to ICD9 codes. In this paper, we identified the medications and diagnoses for 1.3 million individuals at Vanderbilt University Medical Center to evaluate the medication coverage of MEDI and then to calculate the prevalence for each indication for each medication. Our results demonstrated MEDI covered 97.3% of medications recorded in medical records. The "high precision subset" of MEDI covered 93.8% of recorded medications. No significant prescription drugs were missed by MEDI. Manual physician review of random patient records for four example medications found that the MEDI covered the observed indications, and confirmed the estimated prevalence of these medications using practice information. Indication prevalence information for each medication, previously unavailable in other public resources, may improve the clinical usability of MEDI. We believe MEDI will be useful for both clinical informatics and to aid in recognition of phenotypes for electronic medical record-based research.

The Information Warehouse at the Ohio State University Medical Center is a comprehensive repository of business, clinical, and research data from various source systems. Data collected here is a valuable resource that facilitates both translational research and personalized healthcare. The use of such data in research is governed by federal privacy regulations with oversight by the Institutional Review Board. In 2006, the Information Warehouse was recognized by the OSU IRB as an "Honest Broker" of clinical data, providing investigators with de-identified or limited datasets under stipulations contained in a signed data use agreement. In order to streamline this process even further, the Information Warehouse is developing a de-identified data warehouse that is suitable for direct user access through a controlled query tool that is aimed to support both research and education activities. In this paper we report our findings on performance evaluation of different de-identification schemes that may be used to ensure regulatory compliance while also facilitating practical database updating and querying. We also discuss how date-shifting in the de-identification process can impact other data elements such as diagnosis and procedure codes and consider a possible solution to those problems.

Web-technology offers a powerful mechanism for providing access to clinic information. Applications need no longer to be tied to a specific client operating system. The Johns Hopkins Hospital has designed a web based electronic patient record system which seamlessly incorporates multiple web sites. This paper will discuss the motivations for building the system, the architecture, and the challenges faced in designing the architecture.

Successful implementation of integrated clinical information system requires modification of the institution's long range strategic plans and its personnel's behavior. The changes warrant a concerted effort on the part of many different individuals; this paper describes the role of the Information Architect whose primary functions are to steer the process to fulfill stated objectives and build consensus where divergent forces are at work. The workings of the Architect is presented in context of a unique Middle-Eastern institution currently undergoing automation of clinical information.

Described in this paper is the implementation and integration of an obstetrical medical record and database into an existing hospital information system. A unique feature of this system was the integration of existing data captured by the established hospital information systems with the newly implemented obstetrical database to form a complete patient data profile. This complete database integrated data from hospital functions such as demographic data obtained at patient registration, outpatient visits and tests, inpatient admission historical data, tests and procedures, newborn data and miscellaneous data required for birth registration. An important second feature was the utilization of physicians and nurses to enter the obstetrical data. This permitted immediate access to patient data from any hospital information system terminal, immediate retrieval for generating reports, and subsequently, ad hoc queries, statistical analysis and the electronic transfer of birth registration data to the State Vital Statistics Registry.