Computers in Gynecology
Roger P. Smith
Table Of Contents
Roger P. Smith, MD
APPENDIX: GLOSSARY OF COMPUTER TERMS
Like so much of current life, the practice of medicine has clearly entered the computer age. One need look no further to find examples of computers in medicine than the microprocessor-based watch, pager, or cell phone, the hospital information terminal where we get the results of computed tomography, or the security pad that accepts our code number or scans our identification badge to let us into the hospital after hours. Even our car keys have microprocessors to allow us to open the car door as we approach. Patients arrive at the office with computer printouts of information about their symptoms or disease gathered with ease from an Internet that contains more than 4.3 billion connected addresses. Computer technology has rapidly spread throughout the academic and the private sector of American medicine.1,2 From the wards to the office to the coat pocket, computer technology is ubiquitous. A 1982 editorial in the British Medical Journal began with the statement, “Two assumptions seem to underlie all conferences on computers and medicine: first, that their wholesale introduction into all medical activities is inevitable; and secondly that they will be of great benefit.”3 Although the wholesale introduction of computers has not occurred and may not be inevitable, it is apparent that no field of medicine, including gynecology, can escape the influence of computer technology. Unfortunately, the validity of the assumption of universal benefit is much less certain. Despite widespread use and enthusiasm, the value of computers in most aspects of medical practice has yet to be proved, although the skeptics are less righteousness than they once were.
Although the introduction of computers into gynecology has lagged behind some other specialties, it is rapidly catching up. A survey by The American College of Obstetricians and Gynecologists (ACOG) demonstrated that most gynecologists are well aware of the potential of computers in the office setting.4 More than half of the ACOG members surveyed stated that they were already using computers or were planning to begin using them in the near future. More than 20,455 members (more than 44%) of ACOG have registered for access to the member's side of the ACOG Web site, and new registrations average more than 300 per week.
The Internet site averages more than 246,000 hits per day. In December 2002, the ACOG Web site had more than 7.6 million “hits.” That number has increased by seven million over the same period 2 years earlier. Although we are not yet at a stage in which it is essential for every gynecologist to use a computer, it is important for all physicians to at least be aware of what computers can and cannot do. A fundamental knowledge of medical computing will allow us to use this new technology more advantageously.
Computing technology continues to experience an exponential growth. Over the past several decades,Moore's law has described an important factor in this expansion.5,6 Gordon Moore, a cofounder of Intel, noted in the mid 1960s that technology had been doubling the density of transistors on integrated circuits every 12 months. This meant that computers were periodically doubling in capacity and in speed per unit cost. In the mid 1970s, Moore revised his observation of the doubling time to a more accurate estimate of approximately 24 months, and that trend has persisted with minimal change through the end of the past century (Fig. 1).
Today's computers contain circuits connected by wires one-hundredth the size of a human hair. Single computer chips contain billions of diodes, capacitors, and transistors, yet often represent one of the smaller portions of the overall cost of the device. This explosion in capability, speed, and portability has made the microprocessor ubiquitous.
Processors: “The” Computer
Computer processors have been the most visible beneficiaries of the growth described by Moore's law. Many personal computers now can exceed speeds of one gigaflop (one billion additions or subtractions per second), a threshold that results in their being classified as “super computers” and restricting their export from the United States. The result of this growth of capacity is that now desktop and portable machines can display complex and moving images with ease, juggle multiple applications simultaneously (true multithreading), or grapple with elaborate computations or programming steps without noticeable slowing of response. These new machines easily handle large patient databases, patient education materials that include video and audio clips, and physician education modules that can simulate patient interactions such as ultrasonography, hysterography, and virtual reality.7,8,9
Peripheral devices allow computers to gather and disseminate information. At one time, these were limited to printers, monitors, and modems. Peripheral devices now span the range of graphics tablets and fax machines to fetal monitors, blood pressure machines, personal assistants, cell phones, data gloves, and infrared communicators. These devices have expanded the capabilities of the computer and extended their reach into the practice of medicine. Devices now allow the practice of medicine at a distance8,9 or enhance the delivery of care in traditional settings.10 Peripheral devices have even been used to replace other traditional technologies such as X-ray film11,12 assist with neurosurgical procedures,13 or enhance colposcopy14 and the history15 and physical examination16 or evaluate competence in these areas.17,18
Connecting to the Outside World
One “peripheral” that has changed medicine and everyday life has been the connection to the worldwide collections of computers and computer data known collectively as the Internet. The Internet has been described as a library card to the world.19 In the recent past, most of the activity of a computer was expended on manipulation information physically contained at the location of the computer, usually on data storage devices inside or connected to the point of use. Now the computer has become fundamentally a communication devise, processing information that is not physically present near the user. For physicians, the access to information with neither boundaries nor borders offers possibilities of professional education and growth that have never existed before.20 These new opportunities range from the traditional, such as access to literature searches21 and reference libraries22,23,24,25 to a growing list of entrepreneurial continuing education providers and collaborative research.23
The most familiar use of the Internet in medicine is as a fast and efficient path for clinical reference. Many sites can provide access to full text transfer in addition to citations. Examples of this include site access provided as a benefit of traditional paper subscriptions (New England Journal of Medicine) and access provided as part of membership in an organization (ACOG). Simple software and ubiquitous Internet interfaces (browsers) have made it easy to obtain literature searches, online full text, online journals,24 and access to images and photographs. From library computers, home or office sites, or by cellular telephone data links, it is possible to search through libraries around the world.25 Many search engines are available to facilitate this function, but most physicians choose to access this type of information by way of a network or distant server that provides its own search facilities. The most common example in the office setting is accessing the medical literature using a database such as MEDLINE, PubMed, or Grateful Med. There are also specialized databases that contain a subset of the literature focusing on specific subjects. Examples include Toxline and the human genome project. In addition to providing easy access to current articles in the medical literature, they also allow access to a wide range of articles from nonmedical publications. Even full textbooks can now be accessed online.26
Beyond the role of information transfer conduit, the Internet is enjoying a growing role in the education of students, residents, and graduate physicians. A number of sites offer lists of continuing education opportunities or directly provide the education online. Sites of this latter type include those that support forums for discussion, case studies (proctored and unproctored), or formal education programs.
Software is the general term applied to those collections of computer language instructions that tell the computer what tasks to perform on what type of data to obtain a desired result. Although there is more and more software that is specific to a particular segment of medicine, most is general or adapted from nonmedical applications.27 Medical applications can be classified into four broad classifications: information processing, education, administration, and clinical uses.
Databases and the information that they contain drive much of information processing in medicine. Databases store, organize, sort, search, summarize, and report on a set of information. We make lists of things, but databases compile more extensive collections of information that may be manipulated in various ways, including the ability to manipulate the information in ways not anticipated when the information was collected. We might choose to organize a file drawer of patient files by name or identification number only to learn later that these might better be organized by zip code. A computer database can make that change virtually instantly. This approach to information management through readily available commercial software has seen many applications in obstetrics and gynecology. The database management programs currently available allow for a level of programming, error checking, and heuristic decision-making that make natural language outputs, such as narrative discharge summaries, to be generated from what was once viewed as raw data (Fig. 2).
One of the greatest abilities that computers have is the ability to convert and manage information in graphic, or visual, form. In medicine, graphic applications most often include data display and analysis, speaker support, and image processing. Slide production, graphic development, and computer-based presentations are becoming the rule, with many regional and national meetings no longer providing traditional slide projectors without advanced arrangements. Computer-generated images are also used for clinical care in diverse fields,28,29,30 including the teaching of anatomy or trauma care.29
The graphics capabilities of a super computer of 10 years ago can now be found in a child's video game system. This explosion of capability has endowed the personal computer with extraordinary abilities to create, modify, display, and transmit graphic images.30,31 As a result, slide development, desktop publishing, the maintenance of teaching files of microscopic and macroscopic images, image manipulation, video capture, and other tasks have come within the reach of everyone. Physicians have put these abilities to work in the forms of speaker support, teaching files, the visible human project, practice newsletters, and the like. Graphics programs for the creation or modification of images begin at less than $50 but can range to several hundreds of dollars for three-dimensional rendering programs. Whatever the cost, programs of this type are readily available to anyone and may be run (in some form) on even the simplest of today's computers.
The term wetware has been applied to the intellectual, or brain-based, capabilities involved with the computing process. Whereas computing seems to be innate for anyone younger than 15, the skills required for effective computing are fully within the ken of all physicians. The largest impediment to becoming facile with computers is the proliferation of jargon associated with the field (Appendix). Once this hurdle is overcome, computing tends to become addictive. Newcomers to computing should be warned about this phenomenon and reassured that not all of life's tasks are better-managed through the application of microprocessor technology.
Expert Systems and Simulations
Expert systems are not intended to serve as computerized surrogates for physicians. Rather, they are designed to assist physicians in clinical decisions regarding diagnosis and treatment. When used in combination with good (human) clinical judgment, these programs can be effective clinical tools.32 At the same time, they can serve as a teaching aid, helping us to understand the thought process involved in clinical decision-making. Unfortunately, the development of expert systems in clinical medicine has proven to be extraordinarily difficult.33 The few systems that have been developed have received only fair reviews34,35,36 and little implementation.
In gynecology, most expert systems have been confined to relatively well-defined clinical problems. For instance, Chard developed a model expert system for the diagnosis of vaginal discharge.35 For an academic exercise, he compared the diagnostic accuracy of his system versus medical and nonmedical personnel by generating sample cases to be solved by computer and by humans. Overall, the contest ended in a draw.
Riss and associates described two gynecologic expert systems.36 One was developed for the timing of cycle stimulation for patients enrolled in their in vitro fertilization program, and the other was created for preoperative assessment of patients undergoing urinary incontinence procedures. URO-GEN, from the University of Virginia, is an expert system that deals with female urogenital symptoms, focusing on urinary tract infections, vulvovaginitis, salpingitis, and sexually transmitted disease.37 The diagnosis of abnormal vaginal bleeding is another task attempted by gynecologic expert systems.38,39 Other examples include Sexpert,40 for the diagnosis and management of sexual dysfunction, and SELF41 (système en logique floue), which is a French program used for selecting and prescribing contraceptive methods. More recent projects have been of the predictive type, exemplified by efforts to predict fetal acidosis.42 Although there have been a number of projects in gynecology43 and elsewhere,44,45,46 the results have been disappointing and the widespread use of expert systems in clinical medicine appears a long way off.
Greater promise appears to be offered by using neural networks to solve clinical problems. This approach has been applied in a number of areas of medicine,45,46 including a few in the field of obstetrics. Notable among these systems have been ones that estimate fetal weight,47 predict fetal hematocrit in isoimmunized pregnancies,48 and those that interpret nonstress tests49 or manage labor.50 Neural networks offer the possibility of developing an expert system when the exact relationships between factors are either unknown or unknowable.
The use of computers to simulate populations or clinical situations holds some promise for solving problems or predicting outcomes. This type of application has ranged from the effects of changing fee schedules51 to modeling physical performance.52 Simulations have also found application in medical education.53
Risk assessment is another clinical assessment that can be performed with the aid of computer technology. Computer programs for generalized health-risk appraisal have been successfully implemented in various clinical settings for quite some time.54 Other programs have focused on select topics as diverse as the risks of surgical procedures or hemochromatosis.55 Selezneva and coworkers developed a computer program to assess the risk of postoperative complications specifically for patients undergoing gynecologic surgery.56 Computer-assisted risk assessment is also useful in gynecology offices. For example, the risks of oral contraceptive medications can be calculated for individual patients based on age and past medical history, as with the SELF program described earlier. Diaz and coworkers designed a program for initial assessment of patients in a gynecologic clinic, focusing on general risk assessment and assessment of “reproductive health.”57 However, as these authors point out, such programs must be carefully tested before being used in a clinical setting.
The most successful computer-based risk assessment tool in gynecology has been the Gail Model. This risk assessment model is available in formats for common computer platforms, including personal digital assistants (PDA). As prevalent as this program is, it is only one of a growing number of such programs that have been reported in the literature.58
Dosing and Calculation
Several studies have demonstrated the usefulness of computers and calculators in drug dosage determination.59,60 However, most of these studies have focused on the same few drugs: aminoglycosides, digitalis, and phenytoin. Computerized hospital order entry generally incorporates some elements of dosage verification. Most systems will also check for possible drug interactions61 and may provide elements of staff education based on the setting and drug ordered. Whereas the use of computer-aided dosing is hoped to reduce the number of medication-associated errors made,62 not everyone has embraced this implementation.63
As computational devices have grown smaller, their potential applications and markets have grown larger. Nothing illustrates this more than the field of the PDA. Not even widely known as a concept a few years ago, now many people have computing devices to manage appointments, keep track of telephone numbers, document business expenses, send or receive facsimile information, process documents, or perform any number of tasks once reserved for desktop or larger computers. This growth has even undergone its own transformation, as evidenced by the recent increase in the number of hybrid devices that combine the functions of cellular devices with those of the traditional PDA and even digital cameras. These have gained wider acceptance and are seen as a major direction of growth for the computer industry for the coming years. For physicians, these devices may be used to keep track of hospitalized patients, record notes to be placed in a patient's records, enhance resident education,64 or to access drug dosing or other information while away from traditional paper sources.65
Computers are becoming a more common part of everyday patient care. Microprocessors are found in everything from the electronic thermometer used by the nurse to cardiac monitors, from terminals for order entry,66 laboratory reports, and graphic summaries of patient status67 to voicemail systems. Computers may be used to store and study photographic68,69 or imaging data to facilitate patient care.70 Computer access to information and literature references can have a profound impact on clinical decision-making and health care costs.71,72 In gynecology, this has included the computer analysis of colposcopy images.73 Patients may use computers to tract their own health74 or complete a gynecologic history.75 Computers have been used to evaluate the physician–patient interaction76 and how patients make health care choices.77 There are even examples of computers used as translation devices.78
Clinical protocols are especially well suited to computerization, because computers allow customization of the protocol for individual patients. Computerized diagnostic and therapeutic protocols are especially useful for reminding physicians about diseases that are encountered relatively infrequently in clinical practice.79 In fact, some studies have purported to show that computerized protocols can measurably improve the quality of patient care.80 The best example in gynecologic practice is the management of cervical cytology screening with computer-based protocols to facilitate management and follow-up.
The ability to transmit computer data, voice, and visual information rapidly81,82 has led to the development of telemedicine. This application of computers and communication technology has become widely applied in obstetrics and gynecology and other fields.83,84 The technology that allows clinical consultation also opens access to other forms of medical information, resulting in the ability of institutions to be available to even the most remote practitioners.85,86,87,88,89
While the software and computer technology involved is often either transparent or unmodifiable by the end user, virtually all medical imaging is now computer-based. The bedside ultrasonography unit that displays real-time images is a sophisticated computer system that has only a superficial relationship to the cathode ray tube systems of only a few years ago.86 The images studied by radiologists are now routinely captured without film, transmitted to remote locations for interpretation, and stored in computer files that can be access from the clinic or bedside.87,88,89,90,91
The “information age” can been a daunting concept88 until one realizes that information has always been all around us. Now it may be managed, moved, and organized in ways yet to be designed. Information is a vital part of medicine. Computers are “mind amplifiers” that offer the ability to manage this growing quantity of information in useful ways, changing even the way we view information itself.89
Reference Support and Networking
A familiar example of computers in medicine is the use of the computer as a fast and efficient clinical reference source and manager.90 Many of these now provide full text transfer in addition to citations. The most common example in the office setting is accessing the medical literature using a “dial-up” or remote database such as MEDLINE.91 Search interfaces such as Grateful Med and PubMed make this form of access to the National Library of Medicine intuitive and easily mastered. Other examples of computer uses for reference support include tables of normal laboratory values, ultrasonography look-up tables, and prescribing information for medications. In fact, most of the reference materials that physicians commonly use in a clinical setting have been computerized. This text itself is an example. After 70 years in a loose-leaf format, the compact disk read-only memory (CD-ROM)-based edition was introduced in 1997 and now no new subscriptions are available except in the CD-ROM format.
ACOG was one of the first organizations to maintain its own dial-up database, ACOGNET.92 That database contained full-text renditions of virtually all ACOG publications, including technical bulletins, précis, prolog, committee opinions, and more. In addition, ACOGNET had an electronic mail (e-mail) system and various public domain and “shareware” computer programs. This system has been replaced by an extensive presence on the World Wide Web (Internet). The same information and features are included in the ACOG Web site but speed and ability to provide graphics, sound, new forms of navigation, and the creative use of animation have been added. This Web site has a public information side and extensive resources for ACOG members through its members-only side. This site provides the portal to such diverse functions as the posting of profiles for individual practices to the downloading of residence performance reports for the Counsel on Resident Education in Obstetrics and Gynecology in Training examination.
Dial-up databases for searching the medical literature have been available in the clinical setting for quite some time,93 but they are no longer restricted to the watchful eye of the librarian.
Physicians now routinely use databases from home, the office, or the airport. In addition to providing easy access to current articles in the medical literature, some commercial providers also allow access to a wide range of articles from nonmedical publications. Internet search assistants, also known as gophers, have also become available to assist in medical information retrieval.94
Personal computers equipped with CD-ROM devices can take advantage of several commercial vendors who supply CD-ROM versions of the complete (English and foreign) MEDLINE database from 1966 through the present. There are also specialized databases, such as Silver Platter's CANCER-CD, which contains a subset of the literature focusing on a specific subject.95 The Physician's Desk Reference is available in a CD-ROM version or as a PDA. Medical CD-ROM applications that cover the current literature are usually updated quarterly or annually. The wide availability of high-speed Internet connections has supplanted these services and subscriptions for many, but they still offer access for those who travel or have slower connection rates.
The most significant change in the application of computers in obstetrics and gynecology is their use for communications within the Internet.96 The Internet provides a high-speed communications path to computers located virtually anywhere in the world.97,98 The possibilities of individual physicians and hospitals99 are limited only by imagination. An extended discussion of the possibilities offered by Internet access goes beyond the confines of this chapter, although excellent reviews may be readily found elsewhere.100,101,102
Once the province of large institutions and the business community, electronic mail (e-mail) is now the domain of grandmothers and school children. E-mail options are offered by large computer services, via the Internet, or as a part of simple office networking software. By way of e-mail, memoranda, personal or business letters, reprints, patient summaries, or requests for information may be sent and received more quickly than even a facsimile transmission. Even formal or informal consultations now take place through the vehicle of e-mail.101
Variants of e-mail include mailing lists, news groups, and bulletin board systems. Mailing lists and newsgroups provide a structured and formal method of information interchange, but there is a significant difference between the two methods. A mailing list discussion comes directly to your individual electronic mailbox. An example of this is the electronic mailing list for e-mail copies of the table of contents or full text versions of The Centers for Disease Control and Prevention's publications, including Morbidity and Mortality Weekly Report. The messages that form discussions in newsgroups are sent only to the newsgroup administrator, who then sends them to Internet newsgroup system sites (not individual subscribers). You then read the messages in the newsgroup at a particular system site just as you would walk down the hall to read the messages posted on a bulletin board. In fact, the origin of newsgroups was as a bulletin board service in which messages could be posted for all to see. These systems can be very useful of keeping geographically separated members of a group connected or for the dissemination of information quickly.102
Database management systems are computer programs used for storage, retrieval, and analysis of blocks of information. These programs have the capacity to manage large volumes of data with multiple cross-indexes. Most database programs can also exchange data with other programs, such as word processors or spreadsheets. In a gynecologic practice, they are useful in a variety of administrative tasks, including patient files, inventory lists, reference indexes, and more.103 An example of this type of application in women's health care is the use of databases to establish mammography registries.104
Computers have long been synonymous with the high-tech world of research, to the point of being the cinematic staple of any laboratory or “mad scientist.” Computers have been used to provide new insight into many aspects of medicine that would otherwise be impossible to study.105 Computer databases are used to keep track of DNA information106 or interrogate the human genome project.107 Gynecologic applications have included basic investigations into uterine physiology,108,109,110,111,112 fetal behavior,109 and other areas.110
Computer technology has been applied to patient education in two broad ways. The first methods used a computer to generate all the text and graphics displayed on the computer screen, but a substantial amount of direct patient interaction with the computer keyboard was usually required. Nevertheless, despite this drawback, this approach has been successfully used for various patient education projects.111,112,113,114,115 Several commercial programs of this type are available for use in office and hospital settings.112 Among these are a number of programs applicable to gynecology,113 including a series of programs designed to provide informed consent for surgical procedures. A prime example of this type of computer application was the ACOG's Patient Advice and Consent Encounter informed consent program that was offered for several years but was withdrawn from sale in 2000.
A second and much more powerful approach to computer-aided patient instruction is to use a computer in conjunction with another device. The most common example of this is the combination of a computer with a videotape, videodisc,114 CD-ROM, or digital video disk (DVD) system. With this method, the visual quality of the presentations can be excellent, and existing films and videotapes can be easily incorporated into the lessons. In addition, patient interaction with the computer can be greatly simplified. Patients can select a topic from a list that appears on the computer screen. They can then use the computer to control the speed and the progress of the presentation. This simplicity of operation along with the high quality of the visual presentations make the combined approach the logical choice for most private practice settings.
Despite the potential benefits of computers in patient education, this technology has not been widely implemented in the private sector, partly because of physician's concern regarding the willingness of patients to accept the technology. A more important factor was the lack of supporting software from commercial vendors. These are now beginning to come on the scene in the form of CD-ROM products for the home, Internet services, commercial online service providers, and even video games.115 In contrast to this shortage in patient education materials, the availability of software for the education of health professionals is rapidly increasing.
Physician and Staff
Computer-aided instruction (CAI) for health professionals is gaining in popularity, based in great measure on the wide availability of simple, inexpensive tools.116,117,118 The first medical CAI systems were showcase projects developed by and for academic centers. They were usually large, expensive, and limited in scope.117 However, several effective educational systems were developed within academic departments of obstetrics and gynecology. At the University of Arkansas, Jelovsek and associates developed PC-CAI, a microcomputer-based question and answer system for teaching obstetrics and gynecology.118 Initially designed to help house staff prepare for the Committee on Resident Education in Obstetrics and Gynecology (CREOG) examination, PC-CAI was expanded into a more generalized teaching aid for students, nurses, and residents. Databanks of questions compiled to help with student and resident education and to help prepare for examinations of the CREOG type are now available from a number of sources.
Haken and associates at the University of Michigan used a computer conferencing system that became an integral part of their student clerkship in obstetrics and gynecology.119 Using personal computers and terminals connected to the university mainframe computer, students could discuss selected topics with various faculty members, including the chairman. Similar systems are still in use in some departments.120 Studies indicate that computer-based education compares favorably with traditional methods.121,122 With simpler computer systems have come a wide variety of clinical simulations123,124,125,126 and other computer teaching strategies that are gaining acceptance into mainstream medical education.124,125,126,127,128,129,130 These have gone as far as the use of virtual reality to facilitate training in surgical fields.125,126,127,128
Today, a growing number of programs are being produced for the continuing medical education (CME) of practicing physicians. Most of these newer programs are designed to be used in a physician's office with high-speed Internet connections. Many take advantage of the multimedia capabilities of fast personal computers and inexpensive CD-ROM technologies.126,127,128 Some of these programs have been marketed as commercial products, and others have been distributed by pharmaceutical firms as a free service. An excellent example of CME opportunities in obstetrics and gynecology is the ACOG CD-ROM-based programs including colposcopy, ultrasonography, and contraception. Summaries of national meetings, including audio and video recordings of key presentations, are now commonly available from either meeting organizers or commercial sponsors. Examples include synopses of the ACOG annual clinical meeting that have been distributed for the past several years.
As with patient education systems, these programs are most effective when audiovisual capabilities of the computer are fully used. Pictures and diagrams are especially important for the most common CME subjects in gynecology: colposcopy, ultrasonography, cystourethroscopy, and new surgical procedures. Instruction in these subjects clearly requires the effective use of photographs, illustrations, and moving images. With a computer–video combination, any one of the more than thousands of graphic images stored on a CD-ROM, or the millions available on the Internet, can be selected and displayed on the screen in a fraction of a second.127 The same video library used for CAI can also serve as an encyclopedic reference source in a physician's office. Unfortunately, the expense of producing videodisc limited the widespread use of that technology; however, this is not so for the CD-ROM and DVD. More and more of this technology is being ported to the Internet, which allows access to a constantly updated body of information.128
One paradox of computerization has surfaced: as computers enter the realm of clinical practice, they have the potential to displace some of the more traditional opportunities for student and resident education.129,130 Computer-based education also requires exposure, access, and comfort with computer technology, which is not always present.131,132 Like so many aspects of medicine at the dawn of this century, medical education will have to adapt, although it is certain that the future of that educational process will include computers133,134,135 and the Internet.134,135,136
One additional aspect of physician education that has evolved with escalating computer capabilities and the widening availability of the Internet is the tracking of CME credits. Recently, ACOG has introduced online tracking of ACOG cognates earned by fellows.135 As one would expect, this tracks only those cognates reported to ACOG, but most ACOG-sponsored programs now report cognates earned directly to the central database, bypassing the old system of paper records.
Word processing, database management, and scheduling are the three classical nonfinancial applications of computers in practice management. For each of these applications, there is a wide assortment of commercially available programs suitable for use in a gynecologic office setting. Of newer and of potentially greater impact is the use of computers to identify referral requirements, formulary limitations, and other important aspects of managed-care networks.
Paperless Records and Patient Management
The use of a paperless record is a goal that has long-been sought but seldom achieved.138,139 Despite the universal use of computers in hospitals, implementation of a computerized medical record has been disappointing,140 accounting for a small fraction of medical records.141 The process of developing a computerized record is not simple and requires extensive advance preparation to insure efficiency and privacy.142,143,144,145 Despite this, direct access to patient information, such as laboratory reports and other data, even from patients' rooms is becoming common.143
One of the earliest attempts at automation of the outpatient record is the COSTAR project (computer-stored ambulatory record), which was originally developed more than 15 years ago at Massachusetts General Hospital.144 Although the COSTAR system has been used in various clinical settings, there are few examples of it in the specialty of obstetrics and gynecology.145 Another example of a major computerized medical record system is the program developed at Duke University known as the medical record (TMR).146 This system was successfully implemented in the Duke University gynecology clinic and has reportedly been well-received by physicians and staff.147,148 However, although COSTAR and TMR have worked well in a few academic centers, neither system has been adequately tested in an individual or small group practice setting.
A few years ago, two obstetrician–gynecologists in New York developed a physician's workstation to automate the scheduling, billing, and medical record needs of the private practice.149 One of the more interesting aspects of the system was the inclusion of medical record alerts. Based on laboratory, clinical, and historical findings, the program reminds the physician of the need for specific follow-up tests. Another important feature was that the physicians could connect to their office computer remotely while they were at home or in the hospital. Although this system seemed to work well for these two physicians, the program never gained wide acceptance as a commercial product. A recently reported system has used a computer-based record to improve the clinical management of HIV, although this was a narrow and somewhat specialized application.150 There have been some small-scale successes in which a computerized medical record appears to have made a difference,151 but these have been few. What has become apparent from these attempts is the extreme amount of time, effort, and expense that a computer-based medical records system entails.152
The possibility of patient-carried medical records in the form of smart cards has been raised. These are plastic identification cards that have an electronic chip similar to the smart cards introduced by some credit card companies. The chip on these cards retains critical information in computer-readable digital forms. Used like a credit card, these devices could contain the contents of the patient's medical record, recent laboratory and imaging studies, medication history, and other pertinent information. The role that these may have in a future of paperless records is being debated153,154 and is far from clear, with issues including access and privacy still to be resolved.155
There has been a proliferation of clinical computing projects in the gynecologic subspecialty of reproductive endocrinology.156 Reproductive Endocrinology Medical Information System (REMIS) was an ambitious project developed at Johns Hopkins University.157 In addition to research support and medical record functions, this system also provided for patient scheduling. Another example of a comprehensive system is VERGYNIA,158 a microcomputer program design specifically for an infertility clinic. VERGYNIA is a computerized medical record system that consolidates the laboratory, clinical, and historic data needed for the evaluation and management of infertile couples. Unlike the first two examples, most of the more recent reproductive endocrinology programs are smaller, microcomputer-based systems that focus on specific areas, such as postcoital testing159 and in vitro fertilization.160
Although computer applications in gynecologic oncology are fewer and more limited in scope, several early and successful computerization projects have been reported,161 including small computerized tumor registries.162 Others are complex programs used in the planning of treatments for gynecologic oncology patients. For instance, in Germany, Englmeir and associates developed a program that generates three-dimensional reconstructions of pelvic anatomy depicting the location, volume, and radiation dosimetry pattern for individual patients who have gynecologic malignancies.163
A subject more relevant to office gynecology is the management of cervical cytology.164 Smith and associates in England developed the best-known program of this type.165 This system generates letters that tell patients the results of their Papanicolaou (Pap) smear tests and inform patients of the computer's follow-up recommendations. If a patient does not return to the clinic as recommended, the system automatically sends the appropriate follow-up letter. In addition to developing and implementing the system, the authors published a series of articles assessing the effectiveness of the system and analyzing the reasons for patient noncompliance.166 The results of their analysis are pertinent to manual and computerized systems for patient follow-up.
Although completely automated medical records are not common and almost completely absent from most private practice settings, DBMS can be used for other less comprehensive medical record applications.167 For instance, a simple computer file containing patient identification data along with a few important dates (e.g., dates of last Pap smear) can be used to generate appointment reminder letters. Adding a few diagnostic codes to the same database can provide useful practice statistics, letters to referring physicians, or computerized discharge summaries168,169 (see Fig. 2). The number of additional practical applications of DBMS in a physician's office is almost limitless.
Case Lists and Residency Documentation
The task of collecting, organizing, and reporting case experience for individual certification or for the certification of residency programs has become almost exclusively the province of computerized data systems. The American Board of Obstetrics and Gynecology makes available software for personal case list compilation that will run on PC platforms but not on the Macintosh (at this time).170 Although the case lists required for the oral board examination are still submitted as a paper submission, the only practical way of compiling the list is through the use of this or similar software.
Less standardized are packages that have been used for maintaining the records necessary for the process of residency review and certification, although many simple database management systems have been used for many aspects of the record-keeping needed. Beginning in July 2003, The Accreditation Council for Graduate Medical Education mandated that all residency programs in obstetrics and gynecology use an Internet-based reporting system. This system requires that each case is entered individually, with the Web-based system generating the summary statistics that used to be the sole information reported. The transition to this system has not been without problems and the adoption has not been universally enthusiastic, although noncompliance is not an option.
A major nonfinancial administrative application is computerization of scheduling appointments and procedures. A variety of these programs are now available for use in a physician's office, allowing automation of patient appointments and staff scheduling. Although computerized scheduling systems are more efficient than manual methods, they are often unacceptable in a private practice setting. The problem with computerized scheduling system is inflexibility. Older examples of these programs did not adapt well to group practices in which individual physicians vary in their scheduling patterns, although newer versions allow a greater number of choices. Nevertheless, in solo practices and in groups with relatively uniform scheduling patterns, computerized scheduling can be cost-beneficial.
Letters and Follow-up
Word processors are clearly one of the most useful applications of computers in a medical office. Word processing programs allow increased speed, easier error correction, and the ability to check for proper spelling and grammar. Furthermore, word processors can be linked to database programs to generate form letters such as patient appointment reminders. The cost-effectiveness of form letters such as these computer-generated reminders has been demonstrated in various clinical settings.171,172 These letters are especially useful in a gynecologic practice to remind patients about postoperative follow-up examinations and yearly checkups. One study has even looked at the usefulness of computer-generated telephone calls to improve patient compliance with further appointments.173
The automation of the financial aspects of a medical practice is an appealing but potentially dangerous application of computers in a physician's office. When they work well, practice management programs are clearly cost-effective and can save physicians time and money. However, they are also among the most complex and expensive programs used in a private practice setting. In addition, they are often difficult to implement and may not be readily accepted by the office staff. Therefore, all decisions regarding selection and implementation of a practice management system must be carefully considered.
Any practice management package considered for use in a gynecology practice must meet a few basic requirements. First, it must be able to maintain a sufficient number of individual patient data files containing all essential identification and insurance information. Second, it should be able to process claims and generate statements based on a file of individual patient encounters. Finally, based on these and other files, the system must be able to maintain a balanced general ledger and generate various reports. These reports must include older accounts receivable and basic practice statistics.
Most practice management packages offer a number of supplemental features that can be added to the system. The most common of these add-on accessories are patient scheduling and employee payroll programs. Accounts payable and inventory management programs are also frequently offered.
Because most office computer systems were originally designed for nongynecologic practices, they often are not well suited to the needs of our specialty. Consequently, many gynecologists who have attempted to automate their practices have had disappointing, and occasionally disastrous, results. To minimize the risks of such disasters, it is advisable to consider only those programs that have already been successfully implemented in an obstetrics and gynecology office setting. Until quality programs specifically designed for our specialty become available, it is likely that most gynecologists will continue to depend on manual accounting systems for their office practice.
As the administrative demands of clinical practice increase, computerization of diagnostic and therapeutic codes174,175 is becoming increasingly important. Various programs have been developed to help medical personnel translate diagnoses and procedures into standardized codes such as ICD-9 and CPT-4. Programs of this nature are becoming increasingly more important as diagnosis-related groups and other new coding systems are imposed on practicing physicians.
Some third-party payers have made available online interfaces that allow the physician's office to verify coverage or eligibility. These systems have not been widely implemented, and the enactment of extensive protections for patient's privacy will most likely result in the abandonment of the few systems that do exist.
As medicine has become more of a competitive business, computers have taken on a role in practice promotion. This has ranged from the development of practice advertising, newsletters, direct mail information, and even computer-generated telephone follow-ups.176 Speaker support and desktop publishing applications lead the way in more traditional forms of support for practice development and marketing, although the ability to use accounting software to develop managed care proposals, cut overhead costs, and identify the demographics of potential patient populations are gaining importance.
A growing number of practices have elected to have a presence on the Internet with Web pages that promote their practice, provide general medical information, and can even allow patient (with appropriate password protection) to make appointments. The ACOG, through its participation in the Medem consortium, offers the ability to construct Web pages for practice promotion.177 ACOG itself offers information about practices to physicians and patients through its public and members-only Web site.178
Project management is an often-overlooked application of computer technology that may be applied to projects as diverse as the development of a managed care proposal or a research project. This type of software is used to develop critical path (Gant) charts that help manage the resources and time necessary for a given project or group of tasks. To use these programs, a project is broken down into smaller steps with the times, resources, and relations to other elements indicated in a graphical interface. The program will then determine the time needed, the rate-limiting steps, conflicts with resources, and expected milestones. These programs are more familiar in the business world but may find wider use in medicine in the next few years.
|APPENDIX: GLOSSARY OF COMPUTER TERMS*|
*(Reprinted by permission from: Smith RP: The Internet for Physicians, 3rd ed. New York, Springler-Verlag, 2001.)
40. Shortliffe EH: Computer-based clinical decision aids: Some practical considerations In: Lindberg DA, Collen MF, Van Brunt EE (eds): Proceedings of the AMIA Congress. 295, New York, Masson Publishing USA, 1982
46. Scherer WT, White CC, Wilson EC: UROGEN: An expert system for the diagnosis and treatment of female urogenital complaints In: Blum BI (ed): Proceedings of the 11th Annual Symposium on Computer Applications in Medical Care. 189, Silver Spring, Maryland, WIEEE Computer Society Press, 1987
50. Groussin-Weyland M, Landes P, Kohler F et al: Contraception and informatics. SELF, a system to aid medical decisions applied to the prescription of contraceptive methods Rev Fr Gynecol Obstet 81:553, 1986
52. Small SL, Muechler EK: Representing mutually exclusive knowledge in a property hierarchy for a reasoning system in clinical gynecology In: Blum BI (ed): Proceedings of the 9th Annual Symposium on Computer Applications in Medical Care. 304, Silver Spring, Maryland, IEEE Computer Society Press, 1985
61. Keith RDF, Beckley S, Garibaldi JM et al: A multicenter comparative study of 17 experts and an intelligent computer system for managing labor using the cardiotocogram. Br J Obstet Gynaecol 1995;102:688
67. Selezneva ND, Grechikhina NF, Kuzin VF et al: Determination of the degree of risk of postoperative complications occurring in gynecologic patients by using mathematical methods. Akush Ginekol (Mosk) 6:43, 1982
70. Nicholson WF, Jelliffe RW: “Smart” infusion apparatus for computation and automated delivery of loading, tapering, and maintenance infusion regiments of lidocaine, procainamide, and theophylline In: Dayhoff R (ed): Proceedings of the 7th Annual Symposium on Computer Applications of Medical Care. 212, Silver Spring, Maryland, IEEE Computer Society Press, 1983
79. Bishara SE, Cummins DM, Jorgensen GJ et al: A computer assisted photogrammetric analysis of soft tissue changes after orthodontic treatment. Part I: Methodology and reliability Am J Orthod Dentofacial Orthop 107:633, 1995
103. Kalinski T, Hofmann H, Franke DS, Roessner A: Digital imaging and electronic patient records in pathology using an integrated department information system with PACS. Pathol Res Pract 198:10:679-684, 2002
136. Barry MJ, Fowler FJ Jr, Mulley AG Jr et al Patient reactions to a program designed to facilitate patient participation in treatment decisions for benign prostatic hyperplasia. Med Care 33:771, 1995
143. Wheeler LA, Wheeler ML, Ours P et al: Use of CAAI/video in diabetes patient nutrition education In: Dayhoff R (ed): Proceedings of the 7th Annual Symposium on Computer Applications in Medical Care. 961, Silver Spring, Maryland, IEEE Computer Society Press, 1983
172. Fine J, Ashwood ER, Adams JS: Computer-video laser disc systems: Applications in medicine In:. Lindberg DA, Collen MF, Van Brunt EE (eds): Proceedings AMIA Congress. 188, New York, Masson Publishing USA, 1982
197. Osburn AE, Neches NM, Shissler GE et al: Enhancement of COSTAR with a problem oriented record structure and decision making support functions In:. Hefferman SJ (ed): Proceedings of the 5th Annual Symposium on Computer Applications in Medical Care. 1011, Silver Spring, Maryland, IEEE Computer Society Press, 1982
199. Jelovsek FR, Deason BP, Richard H: Impact of an on-line information system on patients and personnel in the medical office In: Blum BI (ed): Proceedings of the 6th Annual Symposium on Computer Applications in Medical Care. 85, Silver Spring, Maryland, IEEE Computer Society Press, 1982
200. Jelovsek FR, Hammond WE, Stad WW et al: Computer base reports for ambulatory care administration management In: Lindberg DA, Collen MF, Van Brunt EE (eds): Proceedings of the AMIA Congress. 10, New York, Masson Publishing USA, 1982
201. Lepper PC, Margulis EB: Multi-user physician workstation for obstetrics and gynecology: A prototype In: Blum BI (ed): Proceedings of the 9th Annual Symposium on Computer Applications in Medical Care. 492, Silver Springs, Maryland, IEEE Computer Society Press, 1985
215. Engelmeir KH, Poppl SJ: A new imaging method and its application in gynecological treatment planning In: Salamon R, Blum BI, Jorgensen M (eds): Proceedings of the 5th Conference of Medical Informatics. 475, Amsterdam, Elsevier Scientific Publishing Co, 1986
224. Turner RC, Peden JG Jr, O'Brein K: Patient-carried card prompts vs computer-generated prompts to remind private practice patients to perform health maintenance measures. Arch Intern Med 154:1957, 1994