WO1998058338A2 - System for providing recommendations to physicians and for managing health care data - Google Patents
System for providing recommendations to physicians and for managing health care data Download PDFInfo
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- WO1998058338A2 WO1998058338A2 PCT/US1998/012849 US9812849W WO9858338A2 WO 1998058338 A2 WO1998058338 A2 WO 1998058338A2 US 9812849 W US9812849 W US 9812849W WO 9858338 A2 WO9858338 A2 WO 9858338A2
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- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06N—COMPUTING ARRANGEMENTS BASED ON SPECIFIC COMPUTATIONAL MODELS
- G06N5/00—Computing arrangements using knowledge-based models
- G06N5/02—Knowledge representation; Symbolic representation
- G06N5/022—Knowledge engineering; Knowledge acquisition
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
- G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H15/00—ICT specially adapted for medical reports, e.g. generation or transmission thereof
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H50/00—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics
- G16H50/30—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics for calculating health indices; for individual health risk assessment
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H70/00—ICT specially adapted for the handling or processing of medical references
- G16H70/20—ICT specially adapted for the handling or processing of medical references relating to practices or guidelines
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H70/00—ICT specially adapted for the handling or processing of medical references
- G16H70/60—ICT specially adapted for the handling or processing of medical references relating to pathologies
Definitions
- the invention is an application of decision support technology to the medical field using computers and relates to the fields of medical diagnosis and treatment, as well as to data processing and recordkeeping.
- the invention provides decision support to physicians based on data entered from a standard clinical contact such as a physician, nurse, or physician assistant.
- the invention also generates reports based on a database of diagnostic evaluations performed by physicians and updates the decision support recommendations based on an analysis of the aggregate data.
- Health care providers must provide an accurate diagnosis and complete and appropriate treatment in an economical and efficient manner.
- the individuars past medical history and other information may be needed for evaluation by the health care provider.
- the health care provider must maintain detailed records on each individual who presents for diagnosis and/ or treatment.
- An economical system for efficiently managing and utilizing these records is necessary to provide proper service. It is necessary for health care providers to maintain detailed longitudinal records of patients with chronic diseases. The individual may need to undergo further testing, treatment and/or monitoring. Many patients need to return for a follow up examination to assess the progression of the medical problem, a prior test, or the results of an earlier treatment.
- the diagnosis (including testing), treatment, and follow up must be competent and economical.
- the invention establishes a system which assists the health care provider in its mission to provide competent and economical service.
- the forms may be difficult to read and may contain incomplete information.
- the conventional computerized format shares the shortcomings of historical documents and folders in that the forms may be incomplete and the coding system employed is based on financial reimbursement and not structured to provide the clinical "best practice.”
- suspected cardiac chest pain has been diagnosed and treated based on an individual physician's knowledge and ability.
- An embodiment of the present invention assists a physician to diagnose and treat suspected cardiac chest pain via aggregate knowledge and using the expertise of cardiac specialists.
- What is needed is a system which aids in the diagnosis and treatment of a patient based on symptoms and signs, not on an already established diagnosis.
- What is needed is a computerized system which identifies and supports proposed courses of treatment to a physician. What is needed is a computerized health care system, which generates reports and statistical analyses concerning the medical service at a health care institution.
- What is needed is a system for ensuring that a physician's diagnosis and treatment plan is fully recorded, in order to help provide feedback to individuals and groups of physicians, and a system designed to change and improve physician practice.
- the invention is a system which supports a physician performing a diagnostic evaluation and treatment on a patient.
- the information concerning this evaluation is stored as part of the patient's medical history in a database.
- An exemplary embodiment is disclosed which relates to a system for aiding in the diagnostic evaluation and treatment of chest pain. This embodiment is directed at diagnosing and treating cardiac ischemia, which is a condition resulting in low blood flow to the heart.
- the present invention provides decision support and presents a reasonable course of action, such as tests to run or treatments to consider based on the patient's symptoms, risk factors, or the results of an earlier test.
- the physician may choose a recommended or a nonrecommended course of action.
- the system will notify the physician that he is deviating from a recommended action. The physician then enters reasons why the recommended action was not followed.
- the system By storing the diagnostic evaluations and treatment decisions (i.e. work-ups) in a database, the system is able to generate reports which are useful for the health care provider.
- the reports include, for example, work-up (i.e. diagnostic evaluation and treatment) reports, pretest assessments, stress tests, angiograms, work-ups per physician, pretest assessments per physician, stress tests per physician, angiograms per physician, facilities, patients, pretest assessment changes, stress test changes and angiogram changes.
- the invention of the present system prompts the physician to enter data from menus or lists.
- the system does not allow the physician to proceed unless a sufficient amount of data is entered. Accordingly, the process of the present invention helps ensure that the evaluation information recorded in the database is complete.
- Figure 1 is a block diagram generally showing "Phase I" and “Phase IV” embodiments of the present invention, including the steps for obtaining information for use in the hardware of Figure 2.
- Figure 2 is a diagram showing the hardware components of the present system in the "Phase II" embodiment.
- Figure 3A is a block diagram generally showing the routines used in the Phase II system of Figure 2.
- Figure 3B is a block diagram generally showing the routines within the Evaluation Routine 600 of Figure 3A.
- Figures 4A, 4B, and 4C are exemplary screen displays from the routines shown in Figure 3A.
- Figures 5 is a block diagram showing the Symptoms Subroutine of the Evaluation Routine shown in Figure 3B.
- Figures 6A, 6B, and 6C are exemplary screen displays from the Symptoms Subroutine shown in Figure 5.
- Figure 7 is a block diagram showing the Risk Factor Subroutine ofthe Evaluation Routine shown in Figure 3B.
- Figures 8A, 8B are exemplary screen displays from the Risk Factor Subroutine shown in Figure 7.
- Figure 9 is a block diagram ofthe Post Risk Selection Subroutine from the Evaluation Routine shown in Figure 3B.
- Figure 10 is a block diagram of the Angiography Subroutine of the
- Figures I IA and 11B are exemplary screen displays from the Angiography Subroutine shown in Figure 7.
- Figure 12 is a block diagram of the Stress Test Subroutine of the Evaluation Routine shown in Figure 3B.
- Figures 13A, 13B, 13C, 13D, 13E, and 13F are exemplary screen displays from the Stress Test Subroutine shown in Figure 12.
- Figure 14 is a block diagram of the Post Test Recommendation Subroutine of the Evaluation Routine of Figure 3B.
- Figure 15 is a block diagram of the System Installation Software.
- Figure 16 is a block diagram of a screen display used to enter a password, for the systems of Figure 15 and Figure 17.
- Figure 17 is a block diagram of the Administrative Software used in Phase III of the invention.
- Figure 18 is an exemplary screen display of the display options step shown in Figure 17.
- Figure 19 is an exemplary screen display of the system maintenance option shown in Figure 18.
- Figure 20 is an exemplary screen display of the export data option shown in Figure 19.
- Figure 21 is an exemplary screen display of the generate reports option shown in Figure 18.
- Figures 22A and 22B are exemplary screen displays (reports) generated in response to the stress test option 903 shown in Figure 21.
- Figure 23 is an exemplary screen display (report) generated in response to the workups per physician option 905 shown in Figure 21.
- Figure 24 is an exemplary screen display (report) generated in response to the physicians option 907 shown in Figure 21.
- Figures 25A and 25B an exemplary screen displays (reports) generated in response to the pretest assessment changes option 909 shown in Figure 21.
- Figure 26 is an exemplary screen display generated in response to the statistics option of Figure 18.
- Figure 27 is an exemplary screen display of statistical graph generated in response to selection of the workups per physician option of Figure 26.
- the invention is a system which enables a physician to follow a guided diagnostic evaluation and treatment recommendation for a patient
- a "work-up” or “evaluation” allows a physician to make a diagnosis and to establish the probability, in a specific embodiment, of whether significant coronary disease is present and to assess its degree of severity.
- the "work-up” also includes symptoms and signs observed by the physician, the results of tests performed on the patient or conclusions reached by the physician, as well as any unique facts or circumstances specific to the patient.
- the "work-up” conducted on the patient is stored as part of the patient's medical history in a computer database.
- the evaluation or “work-up” may also include information related to the treatment (actual and/or recommended), if desired.
- the invention involves four "phases" of operation.
- the first phase shown in Figure 1
- the inforrnation necessary to run the system the inforrnation necessary to run the system
- “knowledge base” is obtained. This information is used as the basis for providing recommendations to physicians based on the physician's observations, patient information, test results, etc.
- the system is used by physicians in their practice.
- the physicians utilize the present invention to support their courses of action.
- the invention provides recommendations/ suggestions to the physicians based on input data.
- the physicians consider the recommendations using their professional judgment, and decide whether to follow the recommendations.
- the "work-ups" are stored in a central database and are accessible to all the physicians.
- the system is used by a system administrator to generate reports and statistical graphs based on the stored "work-ups.”
- the system administrator may or may not be the person who installed the system of Phase II, as shown in Figure 15.
- the decision report recommendations are periodically refined and updated after a review of the aggregate data and in view of the results of the latest research as determined by an expert review panel.
- the present invention provides a system for recommending courses of action to a physician and compiles the physicians' actions and patient's data in a database.
- the system also generates reports and statistical analyses based on the data.
- the system updates recommendations periodically to strive to achieve the "best practice.”
- This invention uses a system/process known as the "best practice,” in that the best available clinical information is used.
- the system has the "best” clinical information available and will provide consistent recommendations based on an action's likelihood of success in a specific patient.
- the "best practice” uses information that is thought to be the most advanced in the field by the practicing experts in the field.
- the system could be set up in ⁇ m alternative embodiment to recommend the most economical procedures in view of the potential health risks. This alternative is not the preferred embodiment, but may be easily implemented by focusing on different criteria in the Phase I process.
- FIG. 1 shows Phase I of the invention.
- the system obtains the information necessary to form a "knowledge base" of information.
- the knowledge base is the information which allows a recommendation to be given based on previously known data and, if necessary, various algorithms.
- the first step 10 is to identify the problem.
- the problem is chest pain, i.e. cardiac ischemia 20.
- the next step is to identify factors which tend to indicate an increased risk 70 of the medical problem, here cardiac ischemia, using the "best practice" process (meaning that the risk factors chosen are the ones which
- risk factors include old age, obesity, and status as a smoker, among others 80 for cardiac ischemia.
- risk factors for chest pain are more fully discussed with reference to Figures 7-9 herein.
- the presenting symptoms are identified 50, using the "best practice" system.
- the presenting symptoms include: chest pain, arm discomfort, epigastric discomfort, etc. . . 60.
- the presenting symptoms are more fully discussed with reference to Figures 5 and 6 herein.
- the presenting symptoms may either tend to indicate cardiac ischemia or tend to negate it. When a symptom negates the medical problem undergoing evaluation, the symptom is helpful because it indicates that the problem is not present.
- the "best practice" process is again used, this time to identify the available diagnostic testing techniques 90 used in the diagnosis of the problem.
- the results of the diagnostic techniques or tests support or reject the existence of the problem in an individual.
- the available diagnostic techniques for chest pain include, among others, stress tests.
- the specific stress tests are exercise stress tests, imaging stress tests, and pharmacologic stress tests 100. These specific tests, and other tests, are described more fully with respect to Figures 10-13 herein.
- the next step is to identify existing treatments 30 for the problem.
- Treatments for patients presenting for possible cardiac ischemia are, for example, medical treatment of coronary artery disease (CAD), interventional cardiology procedures, and bypass surgery 40.
- Treatments, and the other information that is identified in Phase I are identified from the medical literature, experts in the field, experimentation and validation, or other techniques.
- the information is then analyzed 110 to determine all the possible presenting symptoms, risk factors, and diagnostic techniques, and as a result a "knowledge base" is built.
- the analysis includes identifying all the information necessary to obtain the symptoms, risk factors, and the information necessary to conduct diagnostic tests, as well as the information obtained from the results of diagnostic tests.
- the analysis uses the "best practice” technique 120 to determine the "best” techniques for correctly diagnosing the patient.
- the analysis may also consider other information not falling into the previously described categories, such as patient signs or conditions. As a result, in Phase II the "best" diagnostic techniques and treatments are recommended to the physician.
- the "best practice” knowledge base is coded into computer routines
- the computer is configured to accept the data needed by the "best practice” analysis and to provide a consequent
- Figures 5-13, Table 1, Table 2, and the Appendix show one example of the "best practice” computer routines 140 for the chest pain embodiment, as determined from the analysis performed by the present inventors.
- the data for analysis by the "best practice" routines must be selected or entered by the physician/user.
- a staff member, such as a physician assistant, or even the patient, may enter/select the data. Therefore, input/ output routines must be coded 150 into the "best practice" routines.
- the input/output (I/O) routines are important because they are designed to elicit all the necessary information from the physician before proceeding to the next request for input or before providing output.
- the I/O routine may be developed (using known methods) to await the entry of one field of information before providing output or before allowing entry of other fields of information. This means that each field of information must be entered. Using this type of I/O system, it is highly likely that the evaluation will contain a complete record of all the pertinent information known to the physician. For example, in Figures 6B and 6C, the "initial clinical impression" selection cannot be made unless (and is preferably not displayed until) suitable "presenting symptoms" are first entered.
- the I/O routines are in the form of lists 160 (for example, as shown in Figure 6B).
- the options in the list are toggled by the physician, preferably by moving a cursor (via mouse or keyboard) over the option and then typing a "select" command, i.e. such as a mouse button.
- a cursor via mouse or keyboard
- Figure 8A shows both the "HTN" and "Diabetes” options selected from the "Risk Factor" list of options.
- a “help” box is preferably used with and encoded with the I/O routines of the present invention.
- the "help” box displays information concerning the selection. For example, in Figure 4A, the cursor is over the "Next Screen” selection. In this case, the "help” box states “Choose this option to go to the next screen.”
- Multiple “help” boxes may be used, one for the screen generally, and one for the selection.
- An example of multiple “help” boxes is shown in Figure 13D at 163, 165.
- a feature improving the usability of the present invention is presenting terms or definitions only at the time they are needed for the particular decision.
- the "best practice" routines are integrated 170 with the I/O routines so that the necessary information is entered /selected when it is needed.
- the combination of the coded "best practice” routines and the simple and informative I/O routines results in an easy to use and effective system, which maintains all the critical information available to the physician.
- the system uses "evaluation software” 340 to provide recommendations to the physicians, and "administrative software” 330 to maintain the system and generate reports.
- the system is next tested 180 until it has achieved a high degree of reliability.
- the analysis and building of the "knowledge base" 110, the coding of the "best practice” routines 130, the coding of the I/O routines 150, and the integration 170 continues.
- a test group of patients is used to help determine patient safety, physician acceptance, and improve the ability of the system to accurately identify disease.
- a validation study at a hospital may be part of the testing process.
- System Phase II Phase II of the system is for the use of physicians, when appropriate, in their daily practice.
- FIG 2 shows the hardware components of the present system which are generally used in the Phase II embodiment (as well as the testing stage of the Phase I embodiment).
- the system 200 utilizes a computer network 210, including a server 220, with database 230, connected to an administrative computer terminal 240 and a number of local computers 250 (preferably personal computers).
- the computer network 210 may be connected by a firewall & modem 260 to remote computers 280 using telephone communications and telephone network 270.
- the remote computers may connect by modem 290 to the telephone network 270 or be connected in their own network 300 which is, in turn, connected by modem 290 to the telephone network.
- Each computer has an input device such as a keyboard 300, a display 312 or monitor, and may have a printer 320, if desired.
- the database 230 is preferably a relational database.
- the hardware configuration of this system allows the data from the server 220 to be available to any of the local 250 or remote 280 computers.
- Each computer 280 is in operative communication with the server and database.
- the remote computers may be connected via ordinary telephone lines, via the internet, via a dedicated computer network, or via other communications media.
- the system merely consists of one computer connected to the database.
- the computer functions as the administrative unit as well as the input device, and the computer's hard disk drive or floppy disk drive stores the database of information.
- the computers 250, 280 are each located at the place where the physician performs either a diagnosis or a treatment.
- the physician uses the input 300 of the computer to provide data concerning the patients and observes recommendations and confirmation of the entered information on the display 310 or printer 320.
- the computer 250, 280 used by the physician accesses the database to obtain the stored information required for it to function properly. While each computer 250, 280 could execute software stored at the server, it is desired in the preferred embodiment that each computer 250,
- the adrriinistrative computer is loaded with "ad ⁇ iinistrative software" 330 of the present invention. There may be one or several administrative computers
- the present invention provides recommended actions to physicians, but is not designed to supercede, question, or substitute for, the physician's professional judgment.
- the recommendations are to be used by the physician as a decision support tool during the physician's decision process. This may be stated in an introductory screen prior to actually executing any software routines.
- the introductory screen (not shown) may state, for the chest pain embodiment described herein:
- This physician decision support tool is designed to be an informational guideline solely for use by licensed physicians in aiding their clinical diagnosis of possible ischemic cardiac chest pain. This tool was validated by a prospective study conducted at (hospital name), on (number of) patients from (dates). The information derived from that study and contained herein may not apply in every instance to an individual patient or the symptoms presented by such patient. This tool should therefore not be construed as individualized medical advice and is not intended to be a substitute for the individualized medical advice and clinical judgment of a licensed physician.”
- the introductory screen (not shown) is preferably displayed prior to running the Phase II routines described herein.
- Figure 3A is a block diagram generally showing the operation of the evaluation software 340 of the Phase II embodiment.
- the Select Facility Routine 400 is executed. This routine prompts the physician to enter the facility at which the computer 250, 280 is located. This may be done by either typing the facility name or selecting a facility from the list of facilities which exist in the database 230. An example of a facility is the name of the hospital or clinic. This routine is optional because the facility could be preprogrammed into the physician's computer and would not need to be entered. Also, in the case where there was only one facility per database, the facility would not need to be entered. An example of a screen display 405 for the Select Facility Routine is shown in Figure 4A.
- the Select Physician Routine 410 is executed. This routine prompts the physician 420 to enter his/her name into the computer. The physician also indicates 420 whether their status is the primary care physician or a consulting physician. Alternatively, the physician would choose a name from a primary care physician list or consulting physician list, thus, simultaneously entering the status of the physician as well as the physician's name. The physician also enters 420 his/her own personal physician ID code, which is preferably not displayed on the computer screen. The physician is only allowed to proceed if the physician ID code is correct. This is shown at the decision box 440.
- the "select physician” routine only allows the physician to proceed if the physician is authorized at with the previously entered facility. This is shown by the second decision box 440.
- the next routine is the Patient Identification Routine 460, which requires the entry of a patient's identification number 470, such as the patient's Social Security Number. If the patent's identification number is not stored 480 within the database, the Add Patient Routine 490 prompts the physician to enter the patient's relevant information. This information, for example, is the name of the patient, the patient's gender, the patient's race, and the current date. The patient inforrnation is displayed for verification 495 by the physician, as shown for example in the screen display 465 of Figure 4C.
- the next routine is the Select Practice Routine 560.
- This routine displays further nonlimiting examples of the practices covered by the present invention, for example: chest pain, congestive heart failure, valvular heart disease, etc. . . .
- An example of a display screen 505 that includes the Select Practice Routine list 515 is shown in Figure 6A. Because the system of the present invention will be updated periodically to add additional areas of medicine to its coverage, this screen allows the physician to select the area undergoing investigation for the entered patient.
- Inclusion Criteria Routine 510 This allows the physician to screen out patients who do not fit within the analysis capabilities of the present invention.
- the inclusion criteria screen is designed as a "gatekeeper" to help ensure that only the type of patients fitting within the analysis capabilities of the invention are processed by the invention.
- the Inclusion Criteria Routine 510 is closely tied to the scope of the knowledge base. As the complexity of the present invention increases, the inclusion guidelines become broader.
- the inclusion criteria are first displayed 572. The physician selects whether the inclusion criteria are met 574 as applied to the patient. If the inclusion criteria are not met the Phase II embodiment restarts, as shown in Figure 3A. If the inclusion criteria are met, the Phase II embodiment continues.
- the inclusion criteria is generally as follows: "possible or probable myocardial ischemia presenting as chest pain, arm, jaw, infrascapular, or epigastric discomfort; if patient has chronic chest pain, symptoms must have worsened since previous evaluation; do not use if the patient exhibits any of the following: shortness of breath as a solitary symptom, myocardial infarction within six weeks, congenital heart disease, significant valvular disease, idiopathic dilated cardiomyopathy, or post-heart transplantation.” In these latter cases there is an extremely high probability that the patient is not suffering from c ⁇ irdiac ischemia, thus making use of the present invention inappropriate for the specific chest pain embodiment described herein.
- the evaluation routine 600 allows the physician to select the presenting symptoms and/or risk factors and provides a recommendation for further testing or treatment. All of the information concerning the patient, symptoms, risk factors, diagnosis and/or treatment are stored in an evaluation file (not shown) in the relational database 230.
- the Evaluation Routine 600 is the most complicated routine, and is preferably modular in design so that a separate evaluation routine 600 is used for each practice 515 listed in the Select Practice Routine 560. Alternatively, the Evaluation Routine may be one large routine covering every practice 515 listed in the Select Practice Routine 560.
- modular Evaluation Routines may be conceptually simpler in design, but require more overall code when implemented with the other Evaluation Routines.
- a single Evaluation Routine will generally require less code because sub-routines may be shared between the practices, but will be conceptually more complicated.
- the evaluation is complete after the Evaluation Routine 600 is finished executing. At this point, or if the inclusion criteria are not met, the system returns to either the Select Facility Routine 400, Select Physician Routine 410 or Select Patient Identification Routine 460 so that the system may be used for additional facilities, physicians or patients, as appropriate. Preferably the software returns to the "Select Physician" Routine 410 so that the system is available for the next physician who requires its use.
- FIG. 5-13 depict the Evaluation Routine 600 for the chest pain embodiment.
- the Evaluation Routine contains a number of subroutines.
- the subroutines, for the chest pain embodiment are: the Presenting Symptoms Subroutine 500 ( Figures 5,6), the Risk Factor Subroutine 510 ( Figures 7,8), the Post Risk Selection Subroutine 520 ( Figure 9), the Stress Test Subroutine ( Figures 12, 13), the Post Test Recommendation Subroutine 550 ( Figure 14), and the Angiography Subroutine 530 ( Figures 10, 11).
- the Evaluation Routine is exited, the evaluation is saved 531 in the database 230.
- Figure 5 shows the Presentation Symptoms Subroutine 500.
- the first step, shown in Figure 5, is to ask the physician whether this is a new evaluation.
- Figure 6A shows a sample display screen 505 when the Presentation Symptoms Subroutine is entered.
- the physician may select "review previous workup” or "finish existing workup” 517, as shown in Figure 6A. When these options are selected 604, the physician selects a prior workup 606 by date and then whether to go to the beginning or end of the workup 608. At this point, the workup is loaded 610 and processing continues at the desired point. Note that evaluations/workups may be saved and exited and virtually any point in the subroutines. If this is a new evaluation, the physician is prompted to enter the date 612 and the patient's symptoms 614. Preferably, the computer defaults to the current date stored in the computer. Figure 6B shows typical screen display 525 for a new workup.
- the possible symptoms are presented in a list for selection 614 by the physician.
- the displayed symptoms in this embodiment, ⁇ u-e shown in Figure 6B. They are: “chest pain,” “arm discomfort,” “neck/jaw discomfort,” “epigastric discomfort,” “shortness of breath,” and “palpitations.”
- the physician selects 614 each of the symptoms applicable to the patient.
- the "help” box is used to display further information about a selection underneath the pointer/ cursor, or having to do with the page in general.
- the "help" box 519 of Figure 6A is the same no matter where the cursor is positioned, and states, for example: "shortness of breath ⁇ ind/or palpitations alone do not qualify for this guideline.” This informs the physician that insufficient data is available to arrive at an inlti ⁇ il clinical impression based on just these two symptoms. If the presenting symptoms are insufficient to provide an initial clinical impression, the physician may select "previous screen” or “save and exit” to restart or end the Ev ⁇ duation Routine.
- the Presentation Symptoms Subroutine processes the symptom to determine if it is sufficient, along with the previously selected symptoms, to provide an initial clinical impression.
- the subroutine is preprogrammed with the "best practice" system. In this embodiment, any symptoms, except the "shortness of breath” and “palpitations" (either singly or both) are sufficient to provide an initial clinical impression. Thus, if ⁇ iny symptoms ⁇ ire present other th ⁇ in shortness of breath or palpitations 616, the Presenting Symptoms Subroutine proceeds to the selection of an initial clinical impression.
- the "initial clinical impression” options are displayed 618.
- the physician using his/her own judgment, selects an initial clinical impression, in this case “definite cardiac ischemia,” “probable or possible cardiac ischemia” or ''discomfort/pain not from cardiac ischemia,” as shown in Figure 6B.
- the evaluation Routine 500 generates a short report 624 to state the inforrnation entered and the conclusion, and saves the evaluation. The report may be printed, at the physician's discretion 626.
- the Evaluation Routine 600 is then complete. If the physician's initial clinical impression is "definite cardiac ischemia," or "probable or possible cardiac ischemia" the evaluation routine progresses to the risk factor analysis.
- the Risk Factor Subroutine is used to perform the risk factor analysis.
- the Risk Factor Subroutine 510 shown in Figure 7, is used to analyze risk factors which may help in the diagnosis of the chest pain.
- Two sample Risk Factor Subroutine screen displays 535, 537 are shown in Figures 8A and 8B.
- the physician selects risk factors 630 associated with ischemia.
- the factors indicating a risk of cardiac ischemia are: age (i.e. male over 55, female over 60), HTN or hypertension (i.e. blood pressure greater than 140/90 or treated for HTN), smoker (i.e. current or quit within last two years), family Hx or history (i.e. first degree relative with known CAD less than 60 years old), obesity (i.e. greater than 30% over ideal body weight), diabetes (i.e. fasting blood sugar greater than 140 mg/dl or treated for diabetes), dyslipidemia (i.e.
- the "help" box preferably displays information concerning the risk factor. Information is only presented when it would be of help to the user.
- the "help" box states "blood pressure greater than 140/90 or treated for HTN.”
- the computer processes the risk factors to determine the "pretest risk for CAD.”
- three or more risk factors (or "known CAD") 632 result in a high pretest risk 634, two risk factors 636 result in an intermediate pretest risk 638, and zero to one risk factor results in a low pretest risk 640.
- the pretest risk is then displayed for reference by the physici ⁇ m, and is used by the processing step in formulating a recommendation.
- the physician also selects the anginal type 644. As shown in Figure 8A, the possible types include “typical,” “typical/ atypical,” “atypical.”
- the "help” box may display further information when the cursor overlays the anginal type possibilities. For example when the cursor overlays "typical” the help box displays "Symptoms definitely characteristic of myocardial ischemia, reproducibly precipitated by increased cardiac workload (usually exercise) and relieved promptly with rest or NTG (nitroglycerin). An anginal equivalent in the appropriate setting is also considered typical angina. Shortness of breath alone is not considered an anginal equivalent.”
- the "help” box may state: "Symptoms with characteristics of typical (exertional) and atypical components. Shortness of breath alone is not considered an anginal equivalent.”
- the "help” box may state "Symptoms are possibly due to myocardial ischemia, but have one or more features atypic ⁇ il for angina. Shortness of breath alone is not considered an anginal equivalent.”
- C.A.C. Canadian Anginal Classification
- help box states that this classification applies if ordinary physical activity, such as walking and climbing stairs, does not cause angina; angina present with strenuous or rapid or prolonged exertion at work or recreation.
- the "help" box 533 of Figure 8A is shown displaying the further information for C.A.C. type II: Slight limitation of ordin ⁇ -ry activity; walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, in wind, or when under emotional stress, or only during the few hours after awakening; walking more than two blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.
- the type III "help" display would relate to a marked limitation or ordinary physical activity; walking one to two blocks on the level and climbing more than one flight in normal conditions.
- the type IV classification is broken into two subclassifications, stable and unstable.
- the "help" display would relate to an inability to carry on any physical activity without discomfort; discomfort may be present at rest; rest discomfort has not recurred in 48 hours; no previous or current objective evidence of ischemia at rest (ST depression > 1 mm, 80 msec after the J point on EKG.
- the "help" for the type IV (unstable) classification would state: inability to carry on physical activity without discomfort; discomfort may be present at rest; rest discomfort has occurred within last 48 hours, and/or EKG shows objective evidence of ischemia at rest (ST depression > 1 mm, 80 msec after the J point on EKG); type V (atypical chest discomfort (or anginal equivalent) NOT associated with increased cardiac workload (usually exercise), an NOT promptly relieved with rest and/or nitroglycerin).
- the Risk Factor Subroutine processes the inforrnation 648 previously entered or already determined from the inputs, namely the pretest risk of
- CAD high, intermediate, or low
- anginal type either typical, typical/atypical, or atypical
- C.A.C. either I, II, III, IV (stabilized)
- This information 648 uses a lookup table preset with each of the possible entered conditions.
- the lookup table is also preset with recommendations.
- the recommendations correspond to the "best practice” previously discussed, meaning that they are preferred clinical recommendations, as understood by most advanced thinking in the field.
- the lookup table used in the processing of risk factors is as follows
- the "recommendation" from the lookup table corresponding to the entered information is displayed 650, and highlighted in the list of options.
- Figure 8A shows that the recommendation is "non-invasive testing", and this option is highlighted in the list of options.
- the recommendation options are testing options, including: (a) no further diagnostics, (b) non-invasive testing, (c) angiography.
- the recommendation may also be a treatment or combination of two or more of these options, as indicated in the lookup table.
- the recommended post risk options are displayed on the computer screen for selection by the physician 650, with the recommendation shown at the top and the recommended options highlighted in a specific color, preferably green.
- the physician may select 652 any of the possible post risk options, including options which are not
- the physician is prompted to enter reasons for deviating from the recommended treatment 656.
- a screen display 539 showing this "guideline deviation" is depicted in Figure 8B.
- the reasons for deviation could be: (a) professional judgment, (b) referral physician's preference, (c) public safety, (d) patient request, or (e) other.
- the physician is prompted to carefully consider a situation when he is deviating from a recommended course of treatment.
- Post Risk Selection Subroutine 520 is executed.
- the Post Risk Selection Subroutine 520 processes the selected post-risk option.
- the Post Risk Selection Subroutine allows the physician to enter comments 662, and then ends the Evaluation Routine, saving the evaluation/ workup. The physician has decided to forgo further testing.
- the Post Risk Selection Routine 520 branches to the Stress Test Subroutine 540.
- the Stress Test Subroutine 540 is described below with reference to Figures 12 and 13.
- the Post Risk Selection Subroutine 520 branches to the Angiography Subroutine 530.
- the Angiography Subroutine 530 shown in Figure 10, first asks the physician whether the angiography has been completed 670. If the angiography has not been completed, the physician is asked whether an angiography is pending 672. If an angiography is not pending, then the patient must have declined an angiography and the physician is prompted to enter reasons why the patient has declined angiography 674.
- the physician is asked whether the angiography has been scheduled 676. If the angiography has not been scheduled, the Evaluation Routine is ended and the evaluation saved. The physician will reload the evaluation after the angiography has been scheduled.
- the physician is asked to enter the date the angiography will occur 678.
- the Evaluation Routine is then ended and the evaluation saved. The physician will reload the evaluation after the angiography has been completed.
- the display 545 shown in Figure 11A is generated.
- the physician is prompted to enter the date of the angiography 680.
- the physician then is prompted to select a visual assessment of stenosis, and the general results of the angiography 682.
- the physician may select one or more of the following stenosis options (with inforrnation about the stenosis option displayed in the "help" box): (a) left main 50% or greater stenosis (visually assessed diameter stenosis in left main coronary artery of 50% or greater); (b) Other Coronary Arteries- 70% or greater stenosis (severest visually assessed diameter stenosis is 70% or greater in at least one major coronary vessel or first order branch); (c) Other Coronary Arteries- 50-69% stenosis (severest visually assessed diameter stenosis is 50-69% in at least one major coronary vessel or first order branch); (d) Other Coronary Arteries- less than 50% stenosis (severest visually assessed diameter stenosis is less than 50% in at least one major coronary vessel or first order branch).
- the physician is prompted to compare the stenosis to any previously observed stenosis (682), as shown in Figure 11A.
- the options for selection include: “new or progressed” (stenosis is new or has progressed in severity since previous coronary angiogram), “previously noted” (the stenosis was noted on a previous angiogram and has not changed significantly), and “no previous angiography” (no prior angiography for comparison).
- the Angiography Subroutine next asks the physician for the physician's initial recommendation following angiography 684, as shown in Figure 1 IB.
- a list of options 547 is presented for selection, including: “no treatment of coron ⁇ iry ⁇ irtery disease (CAD),” “medical Treatment of CAD,” “interventional cardiology procedure,” and “coronary artery bypass surgery (CABG)".
- CAD coron ⁇ iry ⁇ irtery disease
- CABG coronary artery bypass surgery
- the physician After selecting an initial recommendation following angiography 684, the physician enters any notes or data specific to the patient 686, 544. The evaluation is then complete. The Angiography Subroutine and Evaluation Routines end, and the workup is saved.
- the Angiography Subroutine 530 may be programmed to recommend an initial recommendation following angiography, in the same manner (lookup table) as previously provided for. However, the embodiment shown herein allows the physician to use his/her judgment in selecting the initi ⁇ d recommendation following angiography.
- the Stress Test Subroutine 540 prompts the physician to select from a list of tests 555 which could be performed, shown, for example in Figures 13A and 13B. In the chest pain embodiment, these tests are stress tests. In the present embodiment shown in Figures 13A and 13B, the physician may select from: an imaging stress test, a pharmacologic stress test, or an exercise stress test.
- the "help" box 557 may provide selection criteria concerning the selection of a stress test, when the cursor overlies the stress test selection. Alternatively, each listed stress test may have an adjacent "help" box to provide selection criteria about the test.
- the information criteria for the exercise stress test may be as follows: (1) preferred stress test for most patients, (2) patient must be able to exercise adequately, (a) double product > 20,000 needed for test, (b) B- blockade may limit heart rate response and decrease sensitivity, (3) EKG (ST segments) must be interpretable at rest, (a) no LBBB, pre-excitation, (b) no resting ST segment abnormalities (examples: digoxin ST changes, left ventricular hypertrophy (LVH) ST segment changes, Ischemic ST depression).
- the information criteria for the imaging stress test may be as follows:
- the information criteria for the pharmacologic stress test may be as follows: (1) most useful for patients who cannot exercise adequately, (a) severe peripheral vascular disease, (b) other physical limitations, (examples: musculo-skeletal, neurologic disease, general debility), (2) test of choice with previous indeterminate stress test as a result of double product ⁇ 20,000, (3) helpful in patients with documented chronotropic incompetence leading to inadequate double product, (a) fixed rate heart pacing, (b) severe B- blockade.
- the Stress Test Routine 540 prompts the physician to enter a stress test type 701 (either exercise, imaging, pharmacological, or other).
- the Stress Test Routine 540 tests to see whether the exercise stress test was selected 700. If the exercise stress test was not selected, the routine checks to see whether the imaging stress test was selected 702. If the imaging stress test was selected, then the physician is prompted to select imaging stress test indications 704, as shown in Figure 13A.
- the imaging stress test indications 561, shown in Figure 13A are presented in a list and the "help" box may display information concerning each test indication when overlaid by the cursor.
- the imaging stress test indications are (with Help screen information): (a) left bundle branch block (left bundle branch block is present on resting EKG); (b) baseline ST segments abnormality (baseline EKG shows ST segment abnormalities that will make definitive ST interpretation with stress nondiagnostic (baseline LVH with repolarization changes); (c) known CAD-localization of ischemic bed (patient has known CAD; localization os ischemic bed desirable for prognosis and/or treatment); (d) on medication known to cause ST segment changes (on medication that is known to cause "false positive" ST segment changes (digitalis)); (e) previously indeterminent stress test (results of previous stress testing inconclusive for diagnosis and/or prognosis of CAD); (f) female under 55 years old (risk group where regular exercise stress testing is thought to have a poorer predictive value because of lower incidents of CAD in this population); (g) other (includes physician discretion).
- the imaging stress test indications are saved in the database 230.
- the pharmacologic indications 707 shown in Figure 13B are: (a) inability to exercise due to PVD or peripheral vascular disease (inability to exercise due to symptomatic peripheral vascular disease); (b) inability to exercise other (inability to exercise due to causes other than peripheral vascular disease); (c) previous indeterminate stress test (previous stress test has been indeterminent for diagnosis and/or prognosis of CAD); (d) chronotropic incompetence (documented chronotropic incompetence (fixed rate pacing, severe B-blockade)); (e) other ("other" indications for pharmacologic stress testing including "physician discretion”; please enter indication).
- the selected stress test indications are saved to the database 230 working file.
- the physici ⁇ m is prompted to enter the exercise stress test data 708, as shown on screen 565 in Figure 13C, without first selecting an exercise stress test type (in this embodiment). If the imaging stress test has been selected 702 ( Figure 13A), and the imaging stress test indications selected 704 ( Figure 13A), then the imaging stress test type must be selected, as shown in Figure 13D, and the imaging data entered 712, as shown in Figure 13E.
- the pharmacologic stress test type 714 must be selected (not shown) and the pharmacologic data entered 716, as shown in Figure 13F.
- the screen display for entering the pharmacologic stress test type 714 would be similar to the screen 567 of Figure 13D (imaging stress test type).
- the possible types of stress test may be exercise echo, exercise thallium, exercise cardiolite, or "other".
- the "help" box 165 for the exercise echo imaging stress test may state: (1) most useful for patients with no wall motion abnormality or previous infarction; (2) patient must be able to exercise adequately; (3) must be able to obtain diagnostic echo images; (4) produces resting echo image as secondary benefits.
- the exercise thallium imaging stress test help box may state: (1) most useful for patients with wall motion abnormality or previous infarction; (2) patient must be able to exercise adequately; (3) imaging quality good in almost all patients; (4) delayed vallum imaging (24 hours with reinjectlon), may be helpful to check for viable myocardium in patients with resting perfusion defects.
- the help box for the exercise cardiolite imaging stress test may state:
- the help boxes could also indicate the relative expense of the different tests.
- the bottom of the exercise echo help box could state "less expensive than exercise nuclear imaging," as shown in Figure 13D.
- the help box for the exercise thallium test could state at the bottom "more expensive than exercise echo by 2% - 3%.”
- the exercise cardiolite test help box could state at the bottom "more expensive than exercise echo by 2 - 3 times.” This would enable the physicians to take into account the relative costs of the tests for their patients.
- the "help" box may state: (1) most useful for patients with normal ventricles or with wall motion abnorm ⁇ ility and/ or previous infarctions (provides data on possible mycocardial viability); (2) must be able to obtain adequate echo images; (3) may aggravate tachyarrhythmias (atrial fib, v. tach); (4) better test than adenosine/dipyridamole for patients with bronchospastic disease).
- the "help" box may state: (1) most useful for patients with resting LBBB or potential stress induced tachyarrythmias; (2) useful in patients with norm ⁇ d ventricles, wall motion abnormalities, and/or previous infarctions; (3) imaging quality good in almost all patients; (4) cardiac medications (B- blockade, etc.) and large patient size do not limit its usefulness; (5) may aggravate bronchospasm.
- the physician is prompted to enter the exercise test data 708, as shown in Figure 13C.
- This data includes the testing protocol (Bruce, modified Bruce, Naughton, Balke, other).
- the double product heart rate times systolic blood pressure at maximum exercise
- exercise time minutes, seconds
- date performed ⁇ ire also entered.
- the physician checks whether any negative/positive subjective results and negative/positive/ indeterminate objective results (by EKG) were observed.
- the "help" box may display information concerning the subjective and objective results.
- the help box may state: "no symptoms compatible with myocardial ischemia, (angina or anginal equivalent); shortness of breath alone is not considered anginal equivalent.”
- the help box may state: "symptoms compatible with myocardial ischemia (angina or anginal equivalent); shortness of breath alone is not considered anginal equivalent.”
- the help box may state: "less than 1 mm ST segment depression 80 msec after the 'J' point in exercise or recovery.”
- the help box may state: "greater than or equal to 1 mm ST segment depression 80 msec after the 'J' point in exercise or recovery.”
- the help box may state: "ST segments cannot be interpreted with reasonable certainty secondary to baseline ST changes, artifact, medications or physiologic cause ST segment changes, LBBB, pre-excitation, etc."
- a "high risk positive” objective result (by EKG) may be provided as a selection.
- the help box may state: "(1) exertional or transient ST segment elevation not subtending a 'Q' wave with symptoms at any level of exercise; (2) exertional or transient ST segment depression > 2 mm 80 msec after the 'J' point at any level of exertion with symptoms of ischemia.”
- help box for this result may indicate that the result should be selected if "greater than 10 mm Hg drop in blood pressure during exercise.”
- test data 712 is identical to the data entered in the exercise stress test described previously and shown in Figure 13C.
- imaging stress test shown in Figure 13E, has an additional field specific to the type of imaging test. This field is the "objective special results" field, which lists "negative,” “positive,” and “intermediate” as required selections for the imaging stress test type selected.
- the field relates to "objective results by echo.”
- objective results by echo In this case “negative” may be explained by the “help” box to refer to “no wall motion abnormality consistent with reversible ischemia in exercise or recovery.”
- help box to refer to "no wall motion abnormality consistent with reversible ischemia in exercise or recovery.”
- the "positive” objective result would be caused by "wall motion abnormality consistent with ischemia during exercise,” as explained by the "help” box.
- the “indeterminate” selection corresponds to "assessment of wall motion abnormalities cannot be made with reasonable certainty.” Additionally, other options may be added to the "objective results by echo” screen, including a “high risk positive” selection which relates to "large amount of ischemic myocardium with exercise (multiple wall motion abnormalities), left ventricular (LV) dilation with exercise, decreased or unchanged LV ejection fraction with exercise, ischemic area remote from fixed defect.”
- a "maximum heart rate” field and “maximum dobutamine dose ( g/Kg/Min)” field are added (not shown).
- the pharmacological stress test data contains an "objective special result” field. This field provides a “negative,” “positive,” and “indeterminate” selection based on the type of pharmacological stress test.
- the "help" field provides information concerning which special result should be selected.
- "negative” should be selected if the result is "no wall motion abnormality consistent with reversible ischemia during stress.”
- the “positive” selection should occur when “wall motion abnormality consistent with ischemia during stress.”
- the “indeterminate” selection is proper when "assessment of wall motion abnormalities cannot be made with reasonable certainty.”
- a "high risk positive” selection may be provided for situations where "large amount of ischemic myocardium identified with stress (multiple w ⁇ dl motion abnormalities), LV dilation with stress, decreased or unchanged LV ejection fraction with stress, and/or ischemic area remote from fixed defect.”
- “negative” should be selected when "no area of reversible ischemia identified with stress.”
- the "positive” objective result by adenosine thallium or adenosine cardiolite should be selected when “no area of reversible ischemia identified with stress.”
- a "high risk positive” selection may be provided for cases where "large amount of ischemic myocardium identified with stress or multiple defects, LV dilation with stress, ischemic area remote from fixed defect, ⁇ md/or lung uptake (thallium)."
- imaging, or pharmacologic test data is entered 708, 712, 716, the data is ready for processing.
- the data is processed 718 for post test risk 720.
- the preferred embodiment uses a lookup table containing all the permutations of inforrnation which are possible in response to the selections and ranges input by the physician.
- the exercise stress test lookup table (for the Balke testing protocol) is disclosed at pages 2-4 of the Appendix attached hereto.
- the lookup table for the other testing protocols (Bruce, modified Bruce, or Naughton) may be identical to the Balke lookup table, since each results in the "double product" information.
- the result of the analysis from the lookup table is a post-test risk of either "low,” “intermediate,” "high,” or "indeterminate.”
- the post-test risk is used to obtain a post- test recommendation, using logic chart of Table 2.
- the imaging stress test ⁇ malyzes the imaging stress test data 722, 724 in the same way as that previously described for the exercise stress test.
- the image stress test data is processed by using a lookup table containing the possible permutations of the data which it was possible to enter.
- the lookup table for the imaging stress test (Bruce testing protocol) is shown at pages 5-34 of the attached appendix.
- the lookup table for the other testing protocols (Balke, modified Bruce, or Naughton) may be identical to the Bruce lookup table, since each results in the "double product" information.
- the result of the analysis from the lookup table is a post-test risk 774 of either "low,” “intermediate,” "high,” or "indete ⁇ riinate.” These results are converted into a recommendation via the logic of Table 2.
- the pharmacologic stress test data is entered 716 , it is processed 726 in a similar manner as that of the exercise and imaging stress tests.
- the pharmacologic stress test data is processed by using a lookup table containing the possible permutations of the data which it was possible to enter.
- the lookup table for the pharmacologic stress test (adenosine cardiolite, adenosine thallium, dobutamine echo, dipyridamole (PERSANTINE) cardiolite, dipyridamole (PERSANTINE) thallium) is shown at pages 35-41 of the attached Appendix.
- the result of the analysis from the lookup table is a post-test risk 728 of either "low,” “intermediate,” “high,” or “indeterminate.”
- the post- test risk is used with the logic of Table 2 to provide a recommended action. Note that it is not necessary to include the "high risk positive” (special objective result) selection in the lookup table because if this field is selected the result of post-testing will always be a "high” risk.
- the processing routines always provide a post- test risk of either "low,” “intermediate,” “high,” or “indeterminate.”
- the post- test risk is then displayed on the computer screen, as shown in Figures 13C, 13E, and 13F.
- a post-test recommendation routine 730 then uses its own lookup table to provide a post-test recommendation.
- the post-test recommendations are selected from one or more post-test options, and may be a combination of: "no further testing or ischemia treatment,” medical treatment of ischemia,” “medical treatment and non-invasive retesting,” “imaging or pharmacologic stress testing,” and “angiography.”
- the lookup table (with "help” text) is as follows: Table 2: Post-Test Risk Recommendations Based on Post-Test Risk
- the post-test options are displayed 732, with the recommended option displayed at the top and highlighted in the list, as shown in Figures 13C, 13E, and 13F.
- the "help" box may provide more information, as indicated in the table, on the option on which the cursor is present.
- the physician selects a post-test option 732 and, if a nonrecommended option 734, enters reasons 736 why the option was selected (in a similar manner to that shown in Figure 8B).
- reasons include: “professional judgment,” “referral physician preference,” “public safety,” “patient preference,” and “other”.
- Phase II of the invention provides a system which is able to recommend proposed diagnostic tests and treatments based on a set of test results, risk factors, and symptoms. This type of process is capable of being reproduced in other situations where a cause and effect is known between symptoms, risk factors, and test results.
- the I/O is configured to require preceding fields of information to be entered before displaying later fields of information, the maximum amount of information is retained by the system, assuring the generation of complete records.
- Phase III Phase III - Report Generation ⁇ md System Installation.
- Phase III of the invention shown in Figures 16, 17, 18, 19, 20, 21,
- 22A, 22B, 23, 24, 25A, 25B, 26 and 27, involves the generation of reports and statistical analyses by a system administrator.
- the system administrator also inst ⁇ dls the system and maintains the files, as shown in Figures 15 and 16.
- a system administrator has the relevant software files for Phases II and III installed, maintains the database 230, and generates reports /statistics.
- the present invention is provided with System Installation Software 245. This software, shown in the block diagram of Figure 15, is preset with a system administrator password.
- a system administrator manual (not shown) will normally be provided with the System Installation Software 245 to assist the system administrator in configuring and maintaining the system.
- the system adrninistrator manual will contain the preset password so that the system administrator may gain entry to the system.
- ⁇ ifter startup 800 the system administrator enters the (preset) system adrninistrator password 810.
- An exemplary screen display 815 for entering the system administrator password is shown in Figure 16.
- the options may be to install the system on a network 820 (network 210 and server 220 shown in Figure 2), install a workstation 830 (a computer 250, 280 shown in Figure 2), install a stand alone system 840 (not shown), or to install a software upgrade 850 (to either the network 210, server 220, or computers 250, 280 shown in Figure 2).
- the network and workstation installations run together, on a network computer system, i.e. network 210 and computers 250 of Figure 2.
- a network computer system i.e. network 210 and computers 250 of Figure 2.
- the appropriate files are stored on the network server 220 and accessed by physicians at specified workstations, i.e. the computers 250, 280 shown in Figure 2.
- the install network option 820 runs a routine which installs the relevant files on the network server 220 such as the database 230 (which is installed empty or with sample data) and installs the Administrative Software 240 on the Administration Computer 240.
- the install workstation option 830 may be chosen, which runs a routine to install the Evaluation software 340 on the relevant computers 250, 280 Alternatively this option could be run at the computers 250, 280 to install the Evaluation Routine without using network communication.
- the install stand alone option 840 runs a routine to install the database 230, the Adrriinistrative Software 330, and the Evaluation software 340 on a single computer.
- the install upgrade option 850 runs a routine which adds new files or overwrites previously installed files with the latest version ofthe software. This enables additional features to be added yet maintains the integrity of the system. After installation, the system administrator can run the
- Figure 17 shows a block diagram of the Administrative Software.
- the system administrator enters the system administrator password.
- the previously mentioned screen 815 of Figure 16 may be used to enter the password.
- a number of options 875 are displayed 870 for selection by the administrator 880.
- the options, shown in Figure 18, are "system maintenance,” “generate reports,” or “statistics.”
- System Maintenance Routine 890 is executed.
- a sample screen display 895 for the System Maintenance Routine is shown in Figure 19.
- This routine allows standard system maintenance operations to be performed. For example the system administrator may perform the following operations: edit patients (to add, delete or edit patients), edit consulting physicians (to add, delete or edit consulting physicians), edit primary physicians (to add, edit or delete primary physicians), edit facilities (to add, edit or delete facilities), and set system password.
- the System Maintenance Routine 890 allows workups to be deleted and data to be exported for use in other application programs.
- "edit facilities” option is selected and the list of prior facilities is displayed.
- the system administrator may select a prior facility and delete it, or select an "add facility” option (not shown) and enter the name of new facilities. If a facility is to be deleted, the system prompts the administrator with a warning message.
- the system may be configured so that the deletion of facilities also deletes the associated workups, or the system may require the workups to be individually deleted.
- the delete workups option may be selected to delete a prior workup. This may be necessary, for example, if a patient is deleted. It therefore becomes unnecessary to maintain the patient's workup. This may also be necessary if a physician runs a workup on a patient who does not meet the inclusion criteria. In this case the workup may be deleted to prevent the skewing of results in the reports.
- the "delete workups" option (not shown) is selected, the list of workups is displayed on the screen. A workup may be highlighted and then deleted by the delete workup option.
- the system administrator types in the prior password and the new password. Preferably the new password is entered twice to ensure that the system administrator has not mistyped the password.
- the database may be repaired by selecting a "repair database” option.
- This option basically rearranges the data within the database 230 to be more efficiently retrieved. This should normally be selected every thirty days, depending upon the frequency with which data is entered into the database.
- FIG. 20 shows sample screen displays of the "export options” 897 and "export file name” screens 899 from the "export data” selection.
- the "export data” selection is used to output data to different types of application programs, such as spread sheets or word processors.
- the type of information to export may be selected, i.e., pretest assessment, stress test, angiograms.
- the information for all of the physicians, or for specifically selected physicians, may be selected for export. Further, the information from a specific date range or all date may be selected. Additionally, a record header may be selected for inclusion with the field names.
- the "export data" option is useful for e- orting column headings to application programs.
- the file type and file location 899 may be specified, as shown in Figure 20. III.2. Report Generation.
- a useful feature of the present invention is to generate reports of physician's activities or related to workups, facilities, or patients. As shown in Figure 17, a Report Routine 900 is provided. The Report Routine 900 generates different types of reports.
- the system administrator may choose a type of report and then print or view the report.
- the types of reports are generally shown in Figure 21 (screen display 901) and include: workup table reports (workups, pretest assessments, stress tests, or angiograms) statistics (workups per physician, pretest assessments per physician, stress tests per physician, angiograms per physician) list table reports (tables of facilities, physicians, patients), and change table reports (tables of pretest assessment changes, stress test changes, angiogram changes).
- a workup table report of stress tests 903 is shown in Figure 22A and Figure 22B.
- a statistics report of workups per physician 905 is shown in Figure 23.
- a list table report of physicians 907 is shown in Figure 24.
- a change table report of pretest assessment changes 909 is shown in Figure 25A and Figure 25B. The format and content of the reports is easily modified to include any data in the database.
- the workup table reports may list tables of information related to evaluations.
- the workups report may list workups by date, including patient name, physician name, facility and workup comments.
- the pretest assessment report may list the contents of the pretest risk screen for all workups, including symptoms and risk factors listed by workup date.
- the stress tests report 903 may list the results of all tests run on patients, by workup date (see Figure 22A and Figure 22B).
- the angiogram report may list the results of complete angiograms, by workup date.
- the statistical reports list statistics concerning the physicians.
- the statistics could include the number of workups ( Figure 23), pretest assessments, stress tests, or angiograms per physician.
- the workups per physician report 905 may list the number of completed and uncompleted workups performed by each physician.
- the pretest assessments per physician report may list the actions selected by physicians following the pretest risk assessment, including any guideline deviations.
- the stress tests per physician report may list the number of completed and uncompleted tests per physician.
- the angiograms per physician report may list a number of completed and uncompleted (pending or declined) angiograms performed per physician.
- the list table reports generally list the facilities, physicians and/or patients.
- the facilities report may list all the hospitals and clinics included in the database.
- the physicians report 907 may list all the physician information recorded in the database, including physician security numbers, as shown in Figure 24.
- the patients report may list the names and Social Security Numbers of the patients in the database.
- the change table reports list changes made by the physician.
- the pretest assessment changes report 909 may list all the changes made to previously recorded data on the pretest risk screen, as shown in Figure 25A and Figure 25B.
- the stress test changes report may list all changes made to previously recorded stress test results.
- the angiogram changes report may list all changes made to previously recorded angiogram results.
- a report viewer is also included in the present system.
- the report viewer is shown in Figures 22A, 22B, 23, 24, 25A and 25B.
- the report viewer 955 may list the number of database records queried 911 for the report, the number of database records that fit the query requirements 913, the number of records used for the report 915, and the percentage of queried records used for the report 917.
- the viewer also displays the contents of the report 919.
- Viewer commands include go to the first page of the report 921, go to the last page of the report 923, move ahead one page 925, move back one page 927, stop reading database 929 (if databases access is taking a long time), magnify 931, and print report 933, and may include other well known viewing commands.
- the viewer enables the system administrator to quickly page through the report for information needed by the health care provider's management and to print the report.
- FIG. 17 shows a screen display 941 for the Statistics Routine 910.
- the Statistics Routine generates statistics for the physici ⁇ ins, either separately or in a selected combination.
- the number of workups, pretest evaluations, stress tests, angiograms, pretest evaluation deviations, and stress test deviations per physician may be plotted. Additionally, the types of deviations (such as for deviations from pretest or stress test recommendations) may be plotted per physician.
- the graphs may be formatted for overall total numbers or broken down by physician (either by ID number or by name).
- Figure 27 shows a statistical graph 945 of workups per physician, by physician number.
- the decision support recommendations of Phase II are periodically refined and updated after a review of the aggregate data and in view of the results of the latest research as determined by an expert review panel.
- Phase IV involves the same basic steps shown in Figure 1, and is performed periodically to refine and update the phase II system.
- Phase IV ofthe invention advances in medicine occurring after the previous Phase I/II stages are considered, as relating to risk factors 70, presenting symptoms 50, diagnostic techniques 90, treatments 30 and other inforrnation (110), such as patient signs or the medical literature.
- the "best practice" knowledge base is updated.
- An important part of the Phase IV embodiment is an analysis, in the aggregate, of the stored evaluations /workups from the databases 230. This is shown at step 115 of Figure 1.
- Databases 230 contain actual data which was in many cases entered firsthand by physicians, often in the presence of their patients. Much can be learned from this data, including new risk factors, presenting symptoms, diagnostic techniques, treatments, or other information. The data is valuable because it is obtained firsthand from practicing physicians and relates to actual patients.
- This phase makes use of all the prior workup data. Data entered by physicians when they do not select a recommended course of action, or select an option not provided for in the knowledge base (such as "other" as shown in the various screen displays) is especially helpful. This data provides new information which may be studied by experts in the field to improve the phase II "best practice" system.
- the knowledge base is thus expanded using the experiences (evaluations) recorded in the database 230.
- New code is generated 130 and new I/O routines coded 140 to implement the new knowledge in the knowledge base. Coding the I/O routines preferably also involves generating "help" boxes to explain new options or input fields, or the latest advances incorporated into the system.
- Testing 180 is performed as before, and when complete an update or new program 190 is generated.
- the new program may be installed as shown and described with respect to Figures 15- 16.
- a program update may be installed as shown at option 850 in Figure 15.
- Phase IV updates the present invention to incorporate the latest knowledge in the medical field.
- Imaging Suess Cardiolite Brace 16000-19999 ⁇ 3 00 POSITIVE INDETERMINAT POSI ⁇ VE HIGH Imaging Suess Cardiolile Brace 16000-19999 3 01-600 POSITIVE INDETERMINAT POSI VE HIGH Imaging Suess Cardiolile •Bruce 16000-19999 6 01-9 00 POSITIVE INDETERMINAT POSI ⁇ VE HIGH Imaging Suess Cardiolile Bruce 16000-19999 >9 00 POSITIVE INDETERMINAT POSI ⁇ VE HIGH
- Imaging Suess Cardiolite Brace 2000P--99°9 ⁇ 3 00 POSI ⁇ VE NEGATIVE POSI ⁇ VE HIGH Imaging Suess Cardiolite Bruce 20000-29999 3 01-600 POSITIVE NEGA ⁇ VE POSI ⁇ VE HIGH Imaging Siress Cardiolile Brace 20000-29999 601-900 posmvE NEGA ⁇ VE posmvE HIGH Imaging Siress Cardiolile Brace 20000-29999 >9 00 POSITIVE NEGATIVE posmvE HIGH
- Imaging Siress Cardiolile Brace 20000-29999 ⁇ 3 00 POSITIVE NEGATIVE INDETERMINATE INDETERMINATE Imaging Siress Cardiolite Bruce 20000-29999 3 01-6 00 POSITIVE NEGATIVE INDETERMINATE INDETERMINATE Imaging Suess Cardiolile Bruce 20000-29999 6 01-9 00 POSITIVE NEGA VE INDETERMINATE INDETERMINATE (maging Suess Cardiolite Brace 20000-29999 >9 00 POS ⁇ IVE NEGATIVE INDETERMINATE INDETERMINATE
- Imaging SUess Cardiolite Brace 30000+ ⁇ 3 00 NEGATIVE POSITIVE POSI ⁇ VE INTERMEDIATE Imaging SUess Cardiolite Brace 30000+ 3 01-6 00 NEGATIVE POSITIVE POS ⁇ IVE INTERMEDIATE Imaging Stress Cardiolile Bruce 30000+ 6 01-9 00 NEGATIVE POSITIVE POSITIVE INTERMEDIATE Imaging Stress Cardiolile Bruce 30000+ >90 ⁇ NEGATIVE POSITIVE POSITIVE INTERMEDIATE
- Imaging Suess Cardiolite Bruce 30000+ ⁇ 3 00 NEGATIVE NEGATIVE INDETERMINATE LOW Imaging Suess Cardiolile Bruce 30000+ 3 01-6:00 EGA ⁇ VE NEGATIVE INDETERMINATE LOW Imaging Siress Cardiolile Bruce 30000+ 6.01-9 00 NEGA ⁇ VE NEGATIVE INDETERMINATE LOW Imaging Suess Cardiolite Bruce 30000+ >9.00 NEGA ⁇ VE NEGATIVE INDETERMINATE LOW
- Siress Cardiolile Brace 30000+ Imaging ⁇ 3 00 Suess Cardiolite Bruce NEGATIVE 30000+ INDETERMINAT Imaging Stress Cardiolite 3 01-6 00 INDETERMINATE Brace NEGATIVE I INDETERMINATE 30000+ INDETERMINAT Imaging Siress Cardiolite 6 01-9 00 INDETERMINATE Brace NEGATIVE rNDETERM-NATE 30000+ >9 00 INDETERMINAT INDETERMINATE NEGATIVE
- Test Type Test SubTvoe Protocol Double roduct Exercise Tim, Subiective Result Objective.. Rcjuli Obicclive Special Res
- Imaging Suess Echo Brace ⁇ I6000 ⁇ 300 Imaging Suess Echo NEGATIVE Brace POSITIVE ⁇ 16000 301-600 INDETERMINATE Imaging Suess Echo NEGA ⁇ VE INDETERMINATE Bruce POSITIVE ⁇ 16000 INDETERMINATE Imaging 601-900 SUess Echo NEGATIVE INDETERMINATE Brace POSI ⁇ VE ⁇ I6000 >900 INDETERMINATE NEGATIVE INDETERMINATE POSITIVE INDETERMINATE INDETERMINATE INDETERMINATE
- Imaging Suess Echo Bruce ⁇ I6000 ⁇ 300 Imaging Suess Echo NEGATIVE Bruce NEGATIVE ⁇ I6000 POSITIVE 301-600 Imaging Suess Echo NEGATIVE INTERMEDIATE Brace NEGATIVE ⁇ I6000 POSITIVE 601-900 Imaging S NEGATIVE INTERMEDIATE iress Echo Brace NEGATIVE ⁇ I6000 >900 p osmvE NEGATIVE INTERMEDIATE NEGATIVE p osmvE INTERMEDIATE
- Test Type Test S ⁇ bTy e Pr tocol Double Producl Exercise Tu ⁇ Subieclive Result Pbicciiyc Result Obicclive Special Res Risk Imaging SUcssEcho Bruce ⁇ 16000 >9 00 NEGA ⁇ VE INDETERMINAT POSITIVE HIGH
- Imaging S ess Echo Bruce 20000,-29999 ⁇ 3 00 POSHIVE NEGATIVE NEGA ⁇ VE LOW Imaging SUess Echo Bruce 20000-29999 3 01-6:00 POSHIVE NEGA ⁇ VE NEGA ⁇ VE LOW Imaging SUess Echo Bruce 20000-29999 601-9 00 POSI ⁇ VE NEGA ⁇ VE NEGA ⁇ VE LOW Imaging SUess Echo Bruce 20000-29999 >9 00 POSITIVE NEGATIVE NEGATIVE LOW
- Imaging Suess Echo Brace 20000-29999 ⁇ 3 00 POSITIVE INDETERMINAT NEGA ⁇ VE LOW Imaging Suess Echo Bruce 20000-29999 3 01-6:00 POSHIVE INDETERMINAT NEGA ⁇ VE LOW Imaging Suess Echo Bruce 20000-29999 6 01-9.00 POSHIVE INDETERMINAT NEGA ⁇ VE LOW Imaging Suess Echo Bruce 20000-29999 >9 00 POSITIVE ⁇ INDETERMINAT NEGA ⁇ VE LOW
- Imaging SUess Echo Brace 20000-29999 ⁇ 300 NEGA ⁇ VE INDETERMINAT NEGA ⁇ VE LOW Imaging Suess Echo Brace 20000-29999 301-600 NEGATIVE INDETERMINAT NEGATIVE LOW Imaging Suess Echo Bruce 20000-29999 601-900 NEGATIVE INDETERMINAT NEGA ⁇ VE LOW Imaging Stress Echo Bruce 20000-29999 >900 NEGATIVE INDETERMINAT NEGA ⁇ VE LOW
- Imaging SUess Echo Bruce 20000-29999 ⁇ 300 NEGATIVE INDETERMINAT INDETERMINATE INDETERMINATE Imaging SUess Echo Bruce 20000-29999 301-600 NEGATIVE INDETERMINAT INDETERMINATE INDETERMINATE Imaging SUess Echo Bruce 20000-29999 601-900 NEGA ⁇ VE INDETERMINAT INDETERMINATE INDETERMINATE Imaging Suess Echo Bruce 20000-29999 >9.00 NEGA ⁇ VE INDETERMINAT INDETERMINATE INDETERMINATE
- Imaging SUess Thallium Brace ⁇ 16000 ⁇ 3 00 POSI ⁇ VE INDETERMINAT INDETERMINATE INDETERMINATE
- Suess Thallium Brace Imaging 16000-19999 ⁇ 300 Siress Thallium Bruce NEGATIVE ⁇ NDET ⁇ RMINAT NEGA ⁇ VE Imaging 16000-19999 301-600 Suess Thallium Bruce NEGA ⁇ VE INDETERMINAT NEGA VE INDETERMINATE Imaging 16000-19999 601-900 Suess Thallium Brace NEGATIVE
- Test Type Test SubTvpe protocol Double Product Exercise Tim Subiective Result Obieciivc Result Obiective Special Re? Risk Imaging Stress Thallium Bruce 20000-29999 6 01-9 00 POSI ⁇ VE POSI ⁇ VE INDETERMINATE INTERMEDIATE Imaging Stress Thallium Brace 20000-29999 >9 00 POSHIVE POSI ⁇ VE INDETERMINATE INTERMEDIATE
- Imaging Stress Thallium Brace 20000-29999 ⁇ 3 00 Imaging Suess Thallium NEGATIVE Brace INDETERMINAT POSHIVE 20000-29999 3 01-6 00 maging Suess Thallium NEGA ⁇ VE INTERMEDIATE Brace INDETERMINAT POSHIVE maging 20000-29999 6 01-9 00 Suess Thallium NEGATIVE [INTERMEDIATE Bruce INDETERMINAT POSI ⁇ VE
- Suess Thallium Bruce maging 20000-29999 ⁇ 3 00 Suess Thallium NEGATIVE Bruce INDETERMINAT NEGA ⁇ VE maging 20000-29999 3 01-600 Stress Thallium NEGA ⁇ VE LOW Bruce INDETERMINAT NEGA ⁇ VE naging 20000-29999 6 01-9 00 LOW Suess Thallium NEGATIVE Brace INDETERMINAT NEGA ⁇ VE
Abstract
Description
Claims
Priority Applications (3)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
AU84720/98A AU8472098A (en) | 1997-06-19 | 1998-06-19 | System for providing recommendations to physicians and for managing health care data |
CA002306017A CA2306017A1 (en) | 1997-06-19 | 1998-06-19 | System for providing recommendations to physicians and for managing health care data |
EP98935478A EP1027676A2 (en) | 1997-06-19 | 1998-06-19 | System for providing recommendations to physicians and for managing health care data |
Applications Claiming Priority (4)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
US5097897P | 1997-06-19 | 1997-06-19 | |
US60/050,978 | 1997-06-19 | ||
US90679997A | 1997-08-06 | 1997-08-06 | |
US08/906,799 | 1997-08-06 |
Publications (2)
Publication Number | Publication Date |
---|---|
WO1998058338A2 true WO1998058338A2 (en) | 1998-12-23 |
WO1998058338A3 WO1998058338A3 (en) | 1999-03-11 |
Family
ID=26728919
Family Applications (1)
Application Number | Title | Priority Date | Filing Date |
---|---|---|---|
PCT/US1998/012849 WO1998058338A2 (en) | 1997-06-19 | 1998-06-19 | System for providing recommendations to physicians and for managing health care data |
Country Status (4)
Country | Link |
---|---|
EP (1) | EP1027676A2 (en) |
AU (1) | AU8472098A (en) |
CA (1) | CA2306017A1 (en) |
WO (1) | WO1998058338A2 (en) |
Cited By (14)
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EP1102195A2 (en) * | 1999-11-17 | 2001-05-23 | Hitachi, Ltd. | Method of providing welfare information |
WO2004015602A2 (en) * | 2002-08-06 | 2004-02-19 | Pharmacia Ab | System and method for evaluating the cost-effectiveness of providing growth hormone replacement therapy |
EP1452129A1 (en) * | 2001-10-22 | 2004-09-01 | Olympus Corporation | Diagnosis support apparatus |
US6869399B2 (en) | 2000-10-23 | 2005-03-22 | Celgene Corporation | Methods for delivering a drug to a patient while restricting access to the drug by patients for whom the drug may be contraindicated |
US6908432B2 (en) | 1998-08-28 | 2005-06-21 | Celgene Corporation | Methods for delivering a drug to a patient while preventing the exposure of a foetus or other contraindicated individual to the drug |
US7024397B1 (en) | 2000-07-05 | 2006-04-04 | J. J. Donahue & Company | Method and apparatus for negotiating a real estate lease using a computer network |
US7146343B2 (en) | 2000-07-05 | 2006-12-05 | J. J. Donahue & Company | Method and apparatus for negotiating a contract over a computer network |
US20110210853A1 (en) * | 2008-11-06 | 2011-09-01 | Koninklijke Philips Electronics N.V. | Method and system for simultaneous guideline execution |
WO2012085734A1 (en) * | 2010-12-21 | 2012-06-28 | Koninklijke Philips Electronics N.V. | Method for stepwise review of patient care |
US9247911B2 (en) | 2013-07-10 | 2016-02-02 | Alivecor, Inc. | Devices and methods for real-time denoising of electrocardiograms |
US9254095B2 (en) | 2012-11-08 | 2016-02-09 | Alivecor | Electrocardiogram signal detection |
US9254092B2 (en) | 2013-03-15 | 2016-02-09 | Alivecor, Inc. | Systems and methods for processing and analyzing medical data |
CN106127644A (en) * | 2016-06-22 | 2016-11-16 | 朗森特科技有限公司 | A kind of expert suggestion system for tele-medicine |
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US8419650B2 (en) | 1999-04-16 | 2013-04-16 | Cariocom, LLC | Downloadable datasets for a patient monitoring system |
US9395234B2 (en) | 2012-12-05 | 2016-07-19 | Cardiocom, Llc | Stabilizing base for scale |
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- 1998-06-19 AU AU84720/98A patent/AU8472098A/en not_active Abandoned
- 1998-06-19 EP EP98935478A patent/EP1027676A2/en not_active Withdrawn
- 1998-06-19 WO PCT/US1998/012849 patent/WO1998058338A2/en not_active Application Discontinuation
- 1998-06-19 CA CA002306017A patent/CA2306017A1/en not_active Abandoned
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US6908432B2 (en) | 1998-08-28 | 2005-06-21 | Celgene Corporation | Methods for delivering a drug to a patient while preventing the exposure of a foetus or other contraindicated individual to the drug |
EP1102195A3 (en) * | 1999-11-17 | 2002-07-10 | Hitachi, Ltd. | Method of providing welfare information |
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US7024397B1 (en) | 2000-07-05 | 2006-04-04 | J. J. Donahue & Company | Method and apparatus for negotiating a real estate lease using a computer network |
US7146343B2 (en) | 2000-07-05 | 2006-12-05 | J. J. Donahue & Company | Method and apparatus for negotiating a contract over a computer network |
US7959566B2 (en) | 2000-10-23 | 2011-06-14 | Celgene Corporation | Methods for delivering a drug to a patient while restricting access to the drug by patients for whom the drug may be contraindicated |
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CN106127644A (en) * | 2016-06-22 | 2016-11-16 | 朗森特科技有限公司 | A kind of expert suggestion system for tele-medicine |
Also Published As
Publication number | Publication date |
---|---|
CA2306017A1 (en) | 1998-12-23 |
WO1998058338A3 (en) | 1999-03-11 |
EP1027676A2 (en) | 2000-08-16 |
AU8472098A (en) | 1999-01-04 |
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