Table Of ContentComputers and Medicine
Helmuth F. Orthner, Series Editor
Computers and Medicine
Information Systems for Patient Care
Bruce l. Blum (Editor)
Computer-Assisted Medical Decision Making, Volume 1
James A. Reggia and Stanley Tuhrim (Editors)
Computer-Assisted Medical Decision Making, Volume 2
James A. Reggia and Stanley Tuhrim (Editors)
Expert Critiquing Systems
Perry L. Miller
Use and Impact of Computers in Clinical Medicine
James G. Anderson and Stephen J. Jay (Editors)
Selected Topics in Medical Artificial Intelligence
Perry L. Miller (Editor)
Implementing Health Care Information Systems
Helmuth F. Orthner and Bruce l. Blum (Editors)
Nursing and Computers: An Anthology
Virginia K. Saba, Karen A. Rieder, and Dorothy B. Pocklington
(Editors)
A Clinical Information System for Oncology
John P. Enterline, Raymond E. Lendhard, Jr., and Bruce l. Blum
(Editors)
HELP: A Dynamic Hospital Information System
Gilad J. Kuperman, Reed M. Gardner, and T. Allan Pryor
Decision Support Systems in Critical Care
M. Michael Shabot and Reed M. Gardner (Editors)
M. Michael Shabot Reed M. Gardner
Editors
Decision Support Systems
in Critical Care
With 136 Illustrations
Springer-Verlag
New York Berlin Heidelberg London Paris
Tokyo Hong Kong Barcelona Budapest
M. Michael Shabot, M.D. Reed M. Gardner, Ph.D.
Associate Director of Surgery Co-Director, Medical Computing
Director of Surgical Intensive Care LDS Hospital
Cedars-Sinai Medical Center Salt Lake City, UT 84143 and
Los Angeles, CA 90048-1865 Professor of Medical Informatics
and Clinical Associate Professor of University of Utah
Surgery and Anesthesiology Salt Lake City, UT 84112, USA
UCLA School of Medicine
Series Editor:
Los Angeles, CA 90048, USA
Helmuth F. Orthner, Ph.D.
Professor of Computer Medicine
The George Washington
University Medical Center
Washington, D.C. 20037, USA
Library of Congress Cataloging-in-Publication Data
Decision support systems in critical care I M. Michael Shabot. Reed M.
Gardner, editors. - 1st ed.
p. cm. - (Computers and medicine)
Includes bibliographical references and index.
ISBN-13:978-1-4612-7632-6
1. Critical care medicine-Data processing. 2. Medical
informatics. I. Shabot, M. Michael. II. Gardner, Reed M.
III. Series: Computers and medicine (New York, N.Y.)
[DNLM: 1. Critical Care. 2. Decision Making, Computer-Assisted.
3. Medical Informatics. 4. Decision Support Techniques. WX218
D2944 1993
RC86.7.D445 1993]
616'.028 '0285-dc20
DNLM/DLC
for Library of Congress 93-11902
Printed on acid-free paper.
© 1994 Springer-Verlag New York Inc.
Softcover reprint of the hardcover 1st edition 1994
All rights reserved. This work may not be translated or copied in whole or in part without
the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue,
New York, NY 10010, USA), except for brief excerpts in connection with reviews or
scholarly analysis. Use in connection with any form of information storage and retrieval,
electronic adaptation, computer software, or by similar or dissimilar methodology now
known or hereafter developed is forbidden.
The use of general descriptive names, trade names, trademarks, etc., in this publication,
even if the former are not especially identified, is not to be taken as a sign that such names,
as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used
freely by anyone.
While the advice and information in this book are believed to be true and accurate at the
date of going to press, neither the authors nor the editors nor the publisher can accept any
legal responsibility for any errors or omissions that may be made. The publisher makes no
warranty, express or implied, with respect to the material contained herein.
Production managed by Christin R. Ciresi; manufacturing coordinated by Vincent Sceita.
Typeset by Asco Trade Typesetting Ltd, Hong Kong.
987654321
ISBN-13:978-1-4612-7632-6 e-ISBN-13 :978-1-4612-2698-7
DOl: 10.1007/978-1-4612-2698-7
Series Preface
This monograph series intends to provide medical information scientists,
health care administrators, physicians, nurses, other health care provid
ers, and computer science professionals with successful examples and ex
periences of computer applications in health care settings. Through the
exposition of these computer applications, we attempt to show what is
effective and efficient, and hope to provide some guidance on the acquisi
tion or design of medical information systems so that costly mistakes can
be avoided.
The health care industry is currently being pushed and pulled from all
directions, from clinicians, to increase quality of care; from business, to
lower cost and improve financial stability; from legal and regulatory agen
cies, to provide detailed documentation; and from academe, to provide
data for research and improved opportunities for education. Medical in
formation systems sit in the middle of all these demands. The generally
accepted (popular) notion is that these systems can satisfy all demands
and solve all the problems. Obviously, this notion is naive and is an over
statement of the capabilities of current information technology. Eventual
ly, however, medical information systems will have sufficient functionality
to satisfy most information needs of health care providers.
We realize that computer-based information systems can provide more
timely and legible information than traditional paper-based systems. Most
of us also know that automated information systems provide, on average,
more accurate information because data capture is more complete and
automatic (e.g., directly from devices). Medical information systems can
monitor the process of health care and improve quality of patient care by
providing decision support for diagnosis or therapy, clinical reminders for
follow-up care, warnings about adverse drug interactions, alerts to ques
tionable treatment or deviations from clinical protocols, and more. Since
medical information systems are functionally very rich, must respond
quickly to user interactions and queries, and require a high level of secur-
v
vi Series Preface
ity, these systems can be classified as very complex and, from a develop
er's perspective, also as "risky."
Information technology is advancing at an accelerated pace. Instead of
waiting for three years for a new generation of computer hardware, we
are now confronted with new computing hardware every 18 months. The
forthcoming changes in the telecommunications industry will be revolu
tionary. Within the next five years and certainly before the end of this
century, new digital communications technologies, such as the Integrated
Services Digital Network (ISDN) and very high speed local area networks
using efficient cell switching protocols (e.g., ATM), will not only change
the architecture of our information systems but also the way we work and
manage health care institutions.
The software industry constantly tries to provide tools and productive
development environments for the design, implementation, and mainte
nance of information systems. Still, the development of information sys
tems in medicine is, to a large extent, an art, and the tools we use are
often self-made and crude. One area that needs desperate attention is the
interaction of health care providers with the computer. While the user in
terface needs improvement and the emerging graphical user interfaces
may form the basis for such improvements, the most important criterion
is to provide relevant and accurate information without drowning the
physician in too much (irrelevant) data.
To develop an effective clinical system requires an understanding of
what is to be done and how to do it, and an understanding on how to in
tegrate information systems into an operational health care environment.
Such knowledge is rarely found in anyone individual; all systems de
scribed in this monograph series are the work of teams. The size of these
teams is usually small, and the composition is heterogeneous, i.e., health
professionals, computer and communications scientists and engineers,
biostatisticians, epidemiologists, etc. The team members are usually dedi
cated to working together over long periods of time, sometimes spanning
decades. Clinical information systems are dynamic systems; their func
tionality constantly changes because of external pressures and administra
tive changes in health care institutions. Good clinical information systems
will and should change the operational mode of patient care, which, in
turn, should affect the functional requirements of the information sys
tems. This interplay requires that medical information systems be based
on architectures that allow them to be adapted rapidly and with minimal
expense. It also requires a willingness by management of the health care
institution to adjust its operational procedures, and, most of all, to
provide end-user education in the use of information technology. While
medical information systems should be functionally integrated, these sys
tems should also be modular so that incremental upgrades, additions, and
deletions of modules can be done in order to match the pattern of capital
resources and investments available to an institution.
Series Preface vii
We are building medical information systems just as automobiles were
built early in this century (1910s), i.e., in an ad hoc manner that disre
garded even existing standards. Although technical standards addressing
computer and communications technologies are necessary, they are insuf
ficient. We still need to develop conventions and agreements, and
perhaps a few regulations, that address the principal use of medical in
formation in computer and communication systems. Standardization
allows the mass production of low-cost parts which can be used to build
more complex structures. What are these parts exactly in medical in
formation systems? We need to identify them, classify them, describe
them, publish their specifications, and, most importantly, use them in real
health care settings. We must be sure that these parts are useful and cost
effective even before we standardize them.
Clinical research, health services research, and medical education will
benefit greatly when controlled vocabularies are used more widely in the
practice of medicine. For practical reasons, the medical profession has
developed numerous classifications, nomenclatures, dictionary codes,
and thesauri (e.g., lCD, CPT, DSM-III, SNOMED, COSTAR dictionary
codes, BAlK thesaurus terms, and MESH terms). The collection of these
terms represents a considerable amount of clinical activity, a large portion
of the health care business, and access to our recorded knowledge.
These terms and codes form the glue that links the practice of medicine
with the business of medicine. They also link the practice of medicine
with the literature of medicine, with further links to medical research and
education. Since information systems are more efficient in retrieving in
formation when controlled vocabularies are used in large databases, the
attempt to unify and build bridges between these coding systems is a great
example of unifying the field of medicine and health care by providing
and using medical informatics tools. The Unified Medical Language
System (UMLS) project of the National Library of Medicine, NIH, in
Bethesda, Maryland, is an example of such an effort.
The automation of intensive care units in hospitals has advanced re
markably in the last 20 years. Two decades ago, we barely introduced pa
tient monitoring and automatic alarms when vital signs reached a critical
level. Our efforts to combine expertise from multiple disciplines such as
physiology, biomedical engineering, computer science, biomathematics,
and critical care medicine has resulted in state-of-the-art systems which
utilize decision support technology based on experiences collected from
numerous hospitals (e.g., the APACHE III System) and on rule-based
expert system technology (e.g., intelligent respiratory monitoring for
ventilated patients). Today, intensive care units (ICUs) are full of auto
mated equipment. The problem, however, is not to collect data but to
filter unnecessary redundancies that cause information overload. Today's
decision support systems for ICUs are sophisticated clinical information
systems drawing on many expert experiences. These systems are not only
viii Series Preface
used for patient care but also for the efficient management of ICUs. The
latter is important since ICUs are very expensive suites within a hospital.
The purpose of this series is to capture the experience of medical in
formatics teams that have successfully implemented and operated medical
information systems. We hope the individual books in this series will con
tribute to the evolution of medical informatics as a recognized profession
al discipline. We are at the threshold where there is not just the need but
already the momentum and interest in the health care and computer sci
ence communities to identify and recognize the new discipline called
Medical Informatics.
Washington, DC HELMUTH F. ORTHNER
Preface
Modern critical care is characterized by the collection of large volumes of
data and the making of urgent patient care decisions. The two do not
necessarily go together easily. For many years the hope has been that in
tensive care unit (ICU) data management systems could playa meaning
ful role in ICU decision support. These hopes now have a basis in fact,
and this book will detail the history, methodology, current status, and fu
ture prospects for critical care decision support systems.
Computerized ICU data management is just 25 years old. As editors
we are privileged to bring together a group of authors who are the
pioneers, developers, system managers, and philosophers in this field, the
individuals who transformed the dream into reality. Although this book is
about intelligent systems, it is not about artificial intelligence per se. The
state of the art in critical care and ICU data management does not yet
permit the general application of artificial intelligence techniques, though
it may in the future.
A number of commercially available ICU data management systems
are beginning to reach the level of functionality at which decision support
will be routinely available. In the current era of health care reform,
prospective payment, and cost controls, multiple levels of decision sup
port are required to practice auditable, cost~effective and medically effec
tive critical care. This book will describe those levels, the successes and
failures of past and present systems, and the practical aspects of bringing
such systems to fruition in your own hospital.
Our hope is that this book will serve as an interesting and informative
explanation of where we are in ICU decision support, how we got there,
and where we are headed in the future. Please settle back and enjoy the
trip.
M. MICHAEL SHABOT
REED M. GARDNER
ix
The book is dedicated to my parents, Sam and Mona
Shabot, who gave me everything, asked for nothing
and provided the framework for my life.
M. Michael Shabot
July 1993
November 1993 will be a special month for me. This
book will be printed and my mother will be 95 years
young!! I dedicate this book to her. She has been a
continual inspiration to me all of my life. She has en
couraged each of her five children to be life-long learn
ers. Learning and teaching have been a family value
that I hope I can pass along to my children and to
those I associate with. This specialized book about
decision-making using computers is in large measure a
result of the principles she taught me. When the going
got tough at times it was her lively encouragement and
spirit that encouraged me. Thanks mother.
Reed M. Gardner
July 1993
