New health care technologies, medications, treatments, and

procedures are being developed rapidly, and clinicians are

expected to incorporate them into their daily practices.

Clinicians are also expected to assimilate both old and new

knowledge, apply that knowledge to their patients,

remember each patient’s individual health status and

background, and communicate quickly with patients,

hospitals, and other providers. In the past, meeting these

expectations has often been difficult because systems to

organize, store, and retrieve medical and patient

information had not been developed. But today, computer

systems exist that can help clinicians meet each of these

challenges.

Medical informatics deals with all aspects of understanding

and promoting the effective organization, analysis,

management, and use of information in health care.1 For

over 30 years, the Agency for Healthcare Research and

Quality (AHRQ) has supported research on informatics.

Computer systems and applications, many of which are still

being used today, were developed and tested through

AHRQ-funded research. AHRQ has funded numerous

studies on medical informatics, detailed elsewhere.2 This

report describes only a select few of the computer systems

that are relevant to the problems clinicians face, such as

improving the quality of patient care and patient safety,

preventing medical errors, reducing costs, helping patients

manage their conditions, and minimizing the impact of a

new enemy—bioterrorism. 

Background

Traditionally, the process of organizing, storing, integrating,

and retrieving medical and patient information has been

paper based. But paper-based systems are inefficient for

managing enormous amounts of medical and patient

information that can affect patient care. For example:

• The conventional medical record may be illegible

because it is hand written3 and poorly organized, making

it difficult for physicians to locate the information they

need about past medical tests and their results.4

• Patients who visit more than one health care provider

have several medical records, which often are not shared

with other physicians, laboratories, and hospitals.

Medical Informatics for Better and Safer Health Care

RESEARCH IN ACTION

Agency for Healthcare Research and Quality • www.ahrq.gov

Issue #6 June 2002

Authors: Barbara L. Kass-Bartelmes, M.P.H., C.H.E.S., Eduardo Ortiz, M.D., M.P.H.

Managing Editor: Margaret K. Rutherford

Design and Production: Joel Boches

Suggested citation: Kass-Bartelmes BL, Ortiz E, Rutherford MK. Using informatics for better and safer health care. Rockville (MD): Agency for Healthcare

Research and Quality; 2002. Research in Action Issue 6. AHRQ Pub. No. 02-0031.

Making a Difference

• Computer systems improve quality of care...Page 2

• Computer systems improve medication management and

reduce costs...Page 5

• Computers enhance patient self-management of chronic

disease...Page 6

• Computers can help protect against bioterrorism and

detect disease agents...Page 8

• Research to improve patient safety continues...Page 9
Patient information then becomes fragmented, which

can cause delays, disruptions, or errors in patient care.5

• Over the past 40 years, medical information has grown

at an astonishing rate. For example, MEDLINE®, a

database that contains references to articles in the

biomedical literature and is maintained by the National

Library of Medicine, added more than 460,000

references over the past year. This makes it virtually

impossible for physicians to keep up with the large

amount of information that results from clinical trials

and other studies,6 information that they could be using

to guide their medical decisions. In addition, retrieving

and understanding the information pose another set of

problems.7 As a result, patients sometimes do not

receive care that is based on the best and most currently

available evidence, such as the use of aspirin therapy to

prevent strokes and heart attacks8 and preventive

therapies (for example, the pneumonia and flu

vaccines).9

• Physicians must learn and retain a tremendous amount

of information about antibiotics and the organisms they

treat, including which bacteria are susceptible or

resistant to the antibiotic, what dose the patients should

receive and how frequently they should receive it, how

long the patients need to take the antibiotic, side effects

of the antibiotic, and interactions with other medications

or food.10 As much as 50 percent of antibiotic

prescribing is inappropriate, leading to resistant bacteria,

adverse drug reactions, and increased costs.11 In

addition, although medications may have worked well in

tightly controlled clinical trials, physicians also need to

keep informed about their effectiveness when they are

used regularly in “real” clinical practice.12

• Studies have shown that patients who understand their

conditions and are involved with their doctors in making

health care decisions are better able to deal with their

illnesses. However, patients often do not have access to

accurate and reliable information or are not able to

retrieve, understand, and use this information to meet

their individual needs.13

• Patients with chronic diseases such as diabetes or

congestive heart failure often have to monitor their

blood glucose level, weight, blood pressure, and

medication regimens in their homes. Many times they

must wait until their next scheduled visit to share this

information with their physician, and they often forget

to bring their daily measurements with them when they

see their providers. When changes in a patient’s blood

glucose level or blood pressure are not detected in a

timely manner, the patient’s health can deteriorate,

leading to poorer health outcomes and more costly use

of health care services.14

• Finally, the events of September 11, 2001, and their

aftermath have put the United States on alert and

propelled us toward developing additional computer

systems that can collect, analyze, coordinate, and

distribute health information. Specifically, physicians

and public health workers need to be able to respond

quickly and effectively to bioterrorism—the threat that

disease agents such as anthrax or smallpox will be

released into our environment and infect large numbers

of people. In addition, when mass disasters occur, the

resulting casualties and chaos require a system that can

coordinate health and support services.15

Computer systems improve quality of care

and reduce costs

COSTAR (Computer Stored Ambulatory Record)

The COSTAR system creates and stores an electronic

patient record that includes information from the medical

history, physical examinations, laboratory reports,

diagnoses, and treatments.7 Developed in 1968 at

Massachusetts General Hospital2 and still in use today,16

COSTAR helped to improve quality of care by reminding

physicians of guidelines in clinical practice.3 Not following

guidelines can lead to complications. For example,

rheumatic fever (which can later cause damage to the

valves of the heart) can result from an untreated strep

infection.17

In an AHRQ-funded study within a primary care internal

medicine clinic, 13 guidelines were incorporated into the

COSTAR program to remind physicians to perform specific

screening and preventive measures (Table 1). As a result,

physician practice improved significantly for 10 of these 13

health maintenance measures between 1992 and 1993, and

7 out of 10 continued to show significant improvement in

1997.7

2 www.ahrq.gov
RMRS (Regenstrief Medical Record System)

The RMRS helped Wishard Memorial Hospital in

Indianapolis improve preventive patient care and save

money. This system stores over 30 years of patient data

from emergency department visits, hospital stays, clinic

visits, lab test results, and imaging studies. It generates

flow sheets and reminders, and captures physician orders.5

Two AHRQ-funded studies showed that computergenerated reminders increased preventive care measures.

Between April 1983 and January 1984, physicians and

hospital house staff at Wishard Memorial Hospital’s

General Medicine Clinic received computer reminders

during patients’ clinic visits and/or monthly performance

reports generated after the clinic visits for patients whom

the computer identified as needing certain preventive care,

such as colon cancer and tuberculosis screening,

pneumonia vaccination, medication for high blood pressure,

antidepressants, Pap smears, or mammography.9 When

compared to physicians who did not receive performance

feedback reports or computer reminders, physicians who

did receive such reports or reminders:

• Ordered more preventive care measures. 

• Had a rate of pneumococcal vaccination that was 4 to 7

times higher. 

• Increased their compliance for colon cancer screening

by 50 to 133 percent.

• Increased their compliance rate from 10 to 15 percent

overall.9

A study funded in 2001 by AHRQ showed that physicians

who received RMRS computer-generated reminders had

higher ordering rates for four preventive therapies than

physicians who did not (Table 2).8

Another AHRQ-funded study indicated that automatically

showing clinicians their patients’ previous test results

reduced duplicate testing by 16.8 percent and test costs by

13 percent. Over 16 weeks, during patient clinic visits, the

results of some patients’ past tests would appear on a

computer screen. Physicians who received this computer

www.ahrq.gov 3

Table 1. Changes in compliance rates for computerized guidelines 1 year and 5 years after implementation of a

computerized health maintenance reporting system for patients seen in an ambulatory care practice clinic

Compliance rate 

Preventive/ screening measure 1992 (baseline) 1993 1997

Percent

Cholesterol 72 88 89

Pap smear 64 69 75

Mammogram 63 66 70

Breast exam 77 81 72

Breast exam instructions 8 38 41

Testicular exam 48 59 67

Rectal exam 38 72 67

Fecal occult blood 78 74 60

Flu vaccine 69 67 63

Pneumovax 58 65 55

Measles 19 24 12

Tetanus 7 18 23

Rubella 4 19 14

Source: Morgan MM, Goodson J, Barnett GO. Long-term changes in compliance with clinical guidelines through computer-based reminders. Proc AMIA Symp 1998; 493-7.
display ordered, on average, 8.5 percent less tests for

patients than physicians who did not receive this

information. The result was an average decrease of 13

percent in charges for laboratory tests (Table 3).4

Additional AHRQ-sponsored research revealed that the

RMRS saved $3 million annually on inpatient tests and

medications. When physicians ordered a test or medication

on the computer system, the computer displayed the cost of

the test and whether it had been ordered previously, made

medication recommendations, gave warnings about

dangerous drug interactions, and showed the patient’s active

orders, allergies, diagnoses, vital signs, and test results.

Total charges were less when physicians had access to this

information than when they did not (Table 4).18

The RMRS also improved access to patient records by

emergency departments, helping to reduce fragmentation of

patient information.5 AHRQ and the National Library of

Medicine funded the initial development of the Indianapolis

Network for Patient Care (INPC).19 The network includes

an active surveillance component that incorporates patient

data from 11 hospitals in the Indianapolis metropolitan

area.19 Using INPC, Wishard Memorial Hospital linked its

RMRS patient database with two other hospital emergency

departments.5 When patients were seen in the emergency

departments of the other hospitals, the computer system

matched their data with Wishard’s patient data based on

name, date of birth, sex, and other information.5 When a

match was found, the computer system then printed a

patient report that contained a medical history, past

hospitalizations and clinic visits, immunizations, and

laboratory results.5 At one of the hospitals, simply

4 www.ahrq.gov

Table 2. Percent of hospitalizations during which a

physician ordered therapy for a patient eligible to

receive preventive therapy, May 1997 through

October 1998

Computer No computer

Therapy reminder reminder

Pneumococcal vaccine 35.8 0.8

Influenza vaccine 51.4 1.0

Subcutaneous heparin 32.2 18.9

Aspirin at discharge 36.4 27.6

Source: Dexter PR, Perkins S, Overhage JM, et al. A computerized reminder

system to increase the use of preventive care for hospitalized patients. N Engl J

Med 2001; 345(13):965-70.

Table 3. Test ordering rates and charges over 13 weeks for patient clinic visits with and without computerized

display of past test results.

Per 1,000 visits without Per 1,000 visits with

computerized display computerized display

Test Number of tests Charge Number of tests Charge

Total 553 $13,994 510 $12,171

Electrolyte analysis 232 $4,988 214 $4,596

Blood count 145 $1,959 135 $1,817

Chest x-ray 69 $3,493 59 $3,014

Electrocardiogram 40 $1,799 26 $1,167

Urinalysis 32 $ 275 36 $ 310

Leukocytes 25 $ 272 22 $ 244

Urine culture 8 $ 163 13 $ 263

Upper gastrointestinal 7 $1,045 5 $ 760

Source: Tierney WM, McDonald CJ, Martin DK, et al. Computerized display of past test results. Ann Intern Med 1987; 107(4):569-74.
providing this printed report saved $26.00 in patient costs

per encounter.5 The cost of providing the patient report was

estimated at 20¢.5

Computer systems improve medication 

management and reduce costs

HELP (Health Evaluation through Logical Processing)

The HELP system was developed at LDS Hospital in Salt

Lake City, Utah, with AHRQ support. This integration of

clinical informatics with the business of health care

delivery provides a model for the Nation. HELP is currently

distributed commercially by 3M Company. The HELP

system provides decision support programs such as the

automated antibiotic consultant, which helps physicians

select the best antibiotic for patients.2 The computerassisted decision support programs in the HELP system

allow physicians to directly order antibiotics at bedside

terminals, resulting in improved drug selection and

reductions in adverse drug events and costs. 

In one AHRQ-funded study, the automated antibiotic

consultant program recommended the appropriate

medication regimen for hospitalized patients 94 percent of

the time, compared with the 77-percent success rate for

physicians. The average cost for 1 day of therapy selected

by the antibiotic consultant was $41.08 per patient,

compared to $51.93 for the antibiotics prescribed by

physicians. The majority of physicians who used the

antibiotic consultant said they would recommend it to other

physicians (88 percent), felt that it helped them select the

proper antibiotics (85 percent), and believed that it

improved patient care (81 percent).10

LDS Hospital researchers showed that from 1988 through

1994, the computerized decision support system helped

physicians use antibiotics more effectively and

appropriately, reduced costs and adverse drug events due to

antibiotic therapy, and decreased antibiotic use overall

(Table 5). Even though more patients received antibiotics,

the price of acquiring antibiotics for the hospital increased,

and the number of Medicare patients admitted to LDS

Hospital increased, by 1994 the percent of total medication

dollars spent on antibiotics had decreased.11

Another study showed that from 1994 to 1998, 91.4 percent

of the patients hospitalized in the LDS Hospital intensive

care unit received at least one course of antibiotics. Over

this time period, however, the overall length of stay,

incidence of adverse drug events, and mortality rates

decreased (Table 6) and the antibiotic decision support

program helped to control development of antibioticresistant bacteria. For example, the inappropriate

prescribing of vancomycin (the antibiotic that is effective

against Staph aureus bacteria) decreased.20

ARAMIS (Arthritis, Rheumatism and Aging Medical

Information System)

Developed in 1975-76 at Stanford University School of

Medicine with funding from AHRQ (then the National

Center for Health Services Research), the ARAMIS

www.ahrq.gov 5

Table 4. Differences between hospital charges from April 1990 through October 1991 for inpatients with and

without computerized display of test and medication information

Average charge per admission

With computerized Without computerized

Type of charge display display Difference Percent reduction

Total $6,077 $6,964 $887 12.7

Bed $2,283 $2,551 $268 11.9

Tests $1,621 $1,852 $231 12.5

Medications $1,001 $1,181 $180 15.3

Source: Tierney WM, Miller ME, Overhage M, et al. Physician inpatient order writing on microcomputer workstations. JAMA 1993; 269(3):379-83.
database includes about 17,000 patients with arthritis as

well as older adults without arthritis. These patients are

followed for life, and researchers are continuing to conduct

studies on their diseases, care practices, medical and

surgical treatments, and costs.12 The ARAMIS PostMarketing System (ARAMIS-PMS) follows, studies, and

evaluates the effectiveness, toxicity, and value of therapies

for rheumatic disease once these therapies are in use by the

general public.12 Specifically, these studies examine

whether or not a drug works outside of clinical trials,

identify additional toxicities, assess patient satisfaction, and

investigate cost-effectiveness.12 For example, the ARAMISPMS used ARAMIS data to help evaluate the relationship

of nonsteroidal anti-inflammatory drugs (NSAIDs) such as

ibuprofen and gastrointestinal (GI) complications such as

upper or lower GI bleeding, gastritis, ulcers, and gastric

outlet obstructions.21,23 These studies found that the risk of

being hospitalized was greater for patients taking NSAIDs

than for patients who did not take NSAIDs.21,23 Another

study showed that 81 percent of patients hospitalized for GI

complications who had been taking an H2 antagonist (a

medication to prevent GI symptoms) such as cimetidine,

ranitidine, or famotidine (Tagamet, Zantac, and Pepcid) or

antacids, had no apparent signs or symptoms prior to being

admitted.21,22

Computers enhance self-management of

chronic disease

CHESS (Comprehensive Health Enhancement Support

System)

Developed at the University of Wisconsin-Madison,

CHESS is a system designed to be used on a personal

computer in patients’ homes, especially patients suffering

from a life-threatening disease such as breast cancer, HIV

infection, heart disease, Alzheimer’s disease, or

alcoholism.13 An AHRQ study of HIV patients who used

CHESS showed that they had fewer hospitalizations and a

higher quality of life than patients who received only

standard medical treatment.13 The CHESS computer tools

for AIDS patients include:

• Answers to commonly asked questions.

• A library of full-text articles.

• Descriptions of health services, how to find a provider,

and consumer tips.

6 www.ahrq.gov

Table 5. Changes in antibiotic use, adverse

events, mortality rates, and costs between 1985

and 1994 resulting from computerized antibiotic

decision support program, LDS Hospital

Statistic Baseline (year) 1994

Average number of antibiotic 

doses per patient 19 (1985) 5.3

Patients who received 

antibiotics within 2 hours 

prior to surgery 40% (1985) 99.1%

Rate of adverse drug 

events due to antibiotics 26.9% (1989) 18.8%

Mortality rate from 

antibiotics 3.65% (1988) 2.65%

Total medication dollars 

spent on antibiotics 24.8% (1988) 12.9%

Patients receiving 

antibiotics 31.8% (1988) 53.1%

Source: Pestotnik SL, Classen DC, Evans RS, et al. Implementing antibiotic

practice guidelines through computer-assisted decision support: clinical and

financial outcomes. Ann Intern Med 1996; 124(10):884-90.

Table 6. Impact of computerized antibiotic

decision support program on length of stay,

mortality, and adverse drug events, 

LDS Hospital

Statistic 1994 1998

Intensive care unit 

length of stay 3.63 days 2.80 days

Total hospital length 

of stay 10.28 days 8.84 days

In-hospital mortality 

rate 8.7% 5.2%

Rate of adverse drug 

events 1.22% 0.04%

Source: Burke JP, Pestotnik SL. Antibiotic use and microbial resistance in

intensive care units: impact of computer-assisted decision support. J Chemother

1999; 11(6):530-5.
www.ahrq.gov 7

• A referral system to national information and support

services.

• Tools to assess the patient’s lifestyle and risk factors,

and advice on how to reduce risk.

• A tool that helps patients make decisions.

• An action plan to help patients carry out their decisions.

• Online discussion groups for sharing information and

support.

• The option to ask questions of experts and receive

confidential responses.

• True stories from patients with similar problems.13

The AHRQ-funded study that evaluated the HIV/AIDS

module of CHESS showed that, compared to patients who

received standard care, patients who used the CHESS

program for 2 to 5 months had:

• Better mental capacity.

• A more active lifestyle.

• Lower levels of negative emotion.

• Better social support.

• More involvement in their health care.13

Although CHESS patients and patients who received

standard care had the same number of visits to their

physicians and the emergency department, CHESS patients

were better prepared with questions for their providers

during their visits so their visits were 15 percent shorter.

They also had 47 percent more telephone calls with their

providers because they felt more comfortable about calling.

Patients who received only standard care had 50 percent

more hospitalizations than the CHESS patients. When

CHESS patients were hospitalized, their hospital stays were

39 percent shorter. During the time of the CHESS study,

hospitalization costs for AIDS patients averaged $1,485 per

day. While using the CHESS program, participants lowered

their hospitalization costs by $728 per month. After the

CHESS program was removed, participants continued to

average a reduction of $222 per month in hospitalization

costs.13

SBIR (Small Business Innovative Research)

informatics development

Through the SBIR program, 2.5 percent of a Federal

agency’s extramural budget is set aside for small business

research and development of products that can be

commercialized for public benefit.24 Through this funding,

AHRQ has sponsored the SBIR research program

“Developing Tools to Enhance Quality and Patient Safety

Through Informatics.”25 Contracts awarded under this

program include proposals for developing tools that patients

can use at home to monitor their health, methods for

electronic sharing of patient medical records, Internet-based

communications between patients and providers, handheld

devices for patients and providers, and decision support

applications for patient self-care, patient safety, and chronic

disease management.25 Several of these programs have

developed prototypes of devices that have the potential to

improve patient self-care and self-monitoring.

For example, the Diabetes Assistance Self-care Program for

Youth (DASPY), funded through AHRQ’s SBIR program,

is an Internet-based program designed to help young

patients with Type 1 diabetes control their blood glucose

and medication regimens. AHRQ-funded research showed

that these young patients preferred using an electronic

program rather than a paper-based program (Table 7).

Using a handheld device, patients entered the date and

times they checked their blood glucose and took insulin.26

The device alerted patients that their blood sugar was too

low or too high. It was programmed to ask the patients

questions at the end of the day about their consumption of

carbohydrates and how they felt physically. Patients

transmitted data from the DASPY device to their physicians

every 2 days. Patients reported that the electronic log was

more fun to use, made it easier to send information to their

physician, and was less likely to be lost than the usual paper

log.26

AHRQ funded the development of a weight scale and a

glucose monitor that automatically capture, store, and

transmit patient data electronically using a wireless

network. This allows patients to send important medical

information without having to manually input data.

Therefore, physicians can immediately detect changes in

the patient’s condition. The device can also be programmed

to alert both the patient and the physician if the patient’s

weight or blood sugar levels exceed an established

threshold, leading to faster and better treatment than simply

waiting until the next scheduled appointment, which could

be months away.27

Two other studies that AHRQ is funding involve medical

devices that use wireless Internet technology to monitor

blood pressure and pulse oximetry.14 Pulse oximetry, a
measurement of the amount of oxygen in arterial blood,28 is

often used in patients with congestive heart failure to

determine how well the heart is working to provide

oxygen.14 Because patients with congestive heart failure

often retain fluid, blood pressure measurements also help

indicate how well the heart is functioning. A rise in blood

pressure is often associated with a rise in fluid retention.

Once the devices take a blood pressure or pulse oximetry

measurement, the readings are automatically sent via e-mail

to a central computer.14 If the patient’s measurement

exceeds preset limits, the computer system alerts the health

care provider via voice mail, pager, facsimile, or e-mail.14

By making this communication between the patient and the

provider automatic, changes in the patient’s health status

can be detected quickly.14 The health care provider can also

give feedback or instructions by sending the patient

messages that appear on the medical device.14 This

technology allows the devices to be used either in the home

or while traveling by taking advantage of cellular

technology—the same technology that is used for cell

phones.14

One advantage of wireless medical devices is that they can

be located in any room in the house. For example, the

weight scale can be kept in the bathroom, where most

patients weigh themselves. The devices can be located

anywhere as long as they are within 35 feet of the

telemedicine patient station, which can then relay the

patient’s information to the providers.27

AHRQ research to fight bioterrorism and

improve patient safety continues

AHRQ had already begun funding research to deal with

bioterrorism issues prior to September 11. It continues to

fund research that investigates the effectiveness of

information technology in fighting bioterrorism. In

addition, AHRQ is currently funding many projects that

investigate how technology can help improve patient safety.

Informatics to help identify bioterrorist attacks

Clinicians now need to be able to detect organisms such as

ebola, anthrax, plague, tularemia, glanders, and smallpox

when treating patients who are acutely ill, especially those

who have fever.15 The organisms that cause these diseases

can be spread through the air and have the ability to infect

many people simultaneously.15 Diseases such as anthrax

respond best to early treatment and must therefore be

detected quickly.15 Research projects have focused on

helping hospitals and health care systems respond to

bioterrorism emergencies, improve communication among

various health systems, and train health care providers.29

While most of these projects are still ongoing, some of their

8 www.ahrq.gov

Table 7. Preferences among patients ages 6-20 with Type 1 diabetes in using an electronic log compared to a

paper log

Question Electronic* Paper*

Which log was more fun to use? 79% 17%

Which log was easier to remember to use? 58% 33%

Which log was easier for sending information to your doctor? 71% 25%

Which log is more likely to be misplaced or lost? 17% 83%

Which log would be easier to carry around? 58% 42%

Which log would encourage you to log your blood sugar and 

other information more often? 62% 33%

Which log would you prefer to use in the future? 67% 33%

*Note: Totals may not add to 100% because of missing data.

Source: Sharma S. Web-based tool for diabetes self-care. Final report. Watertown (MA): New England Research Institutes; 2001. Contract No. 290-00-0025. Sponsored by the Agency

for Healthcare Research and Quality.
results are already helping clinicians and public health

workers respond to bioterrorism and other disaster threats. 

In order to help clinicians detect these diseases faster,

AHRQ is funding continuing medical education (CME)

training through the University of Alabama at Birmingham

(UAB).30 Along with researchers at the Research Triangle

Institute, researchers at UAB have developed online

training modules for anthrax, smallpox, botulism,

tularemia, viral hemorrhagic fever, and plague.30 As of

April 2002, UAB had awarded 883 continuing education

credits.31 The UAB CME Web site can be accessed at

<http://www.bioterrorism.uab.edu/>.

AHRQ-sponsored researchers at the University of

Pittsburgh have demonstrated that early detection of

infectious disease is possible using the Real-time Outbreak

and Disease Surveillance (RODS) computer system.15

Several studies using data from emergency department

visits, such as laboratory test results and patient

demographic information, showed that the RODS computer

system detected acute respiratory illnesses and influenza far

more quickly than standard methods of detection.15 The

RODS computer system provides descriptions of symptoms

that precede the physical presentation of diseases such as

botulism, encephalitis, respiratory diseases, hemorrhagic

diseases, diarrheal diseases, and viruses.19 When patients

begin exhibiting symptoms of one of these types of

diseases more frequently than is considered normal, a

notification system is engaged.19 Physicians who have

public health, emergency, and infectious disease training

monitor this system and report suspicious events to the

public health departments.19

An AHRQ project at Children’s Hospital in Boston is

developing computer systems that collect and analyze

emergency department data, incorporate an online

diagnosis and treatment manual, and use a decision support

system specifically designed to detect diseases early.19 To

help clinicians identify the diseases that result from

bioterrorism, the Massachusetts Institute of Technology has

created a Web-based decision support tool that links patient

symptoms and signs with a database of potential organisms

and a treatment manual.19

Continuing its support of the Regenstrief Institute at

Indiana University, AHRQ is funding a project that uses

the Indianapolis Network for Patient Care to collect patient

data such as lab results, clinic notes, chief complaint,

diagnoses, procedures, immunizations, allergies,

medications, and test results. When the system identifies

cases of a reportable condition, it copies the patient

information to the county and State health departments. It

also sends e-mail summaries to public health officers and

investigators.19

For additional information on AHRQ’s continuing research

on bioterrorism, see AHRQ Publication No. 02-P018 at

<http://www.ahrq.gov/news/focus/bioterror.htm>.

Patient safety programs that use medical informatics

AHRQ is continuing to sponsor research promoting the use

of informatics to ensure patient safety. Projects funded

under the Clinical Informatics and Patient Safety (CLIPS)

research program are examining how informatics can

improve decisionmaking and patient safety while reducing

errors and maintaining patient confidentiality.32

• Improving Primary Care Patient Safety with Handheld

Decision Support Systems; Grant No. R18 HS11820.

This project will examine the acceptance of, benefits of,

and barriers to the use of stand-alone, handheld decision

support systems (DSSs) in an ambulatory setting to

improve prescribing patterns in order to prevent

medication errors. It will also study the clinical impact

and cost-effectiveness of point-of-care, handheld

ambulatory DSSs on medical errors. A suite of decision

support tools will be implemented in a number of

ambulatory clinics, and the investigators will assess the

extent to which potential or perceived barriers influence

their use. 

• Impact of Personal Digital Assistant Devices on

Medication Errors; Grant No. R18 HS11808. This

study will assess the impact of personal digital assistants

(PDAs) on reducing medication errors in primary care

office-based practices. Researchers will also measure

the occurrence of potential preventable medicationrelated errors, assess physicians’ attitudes toward the

PDAs, and identify barriers perceived by physicians to

PDA use in practice and successful strategies to

overcome these barriers. 

• Using Handheld Technology to Reduce Errors in

Attention-Deficit Hyperactivity Disorder Care; Grant

No. R18 HS11859. This project will use a real-time

point-of-care handheld computerized decision support

module called DS-ADHD to reduce medical errors in

the treatment of attention-deficit/hyperactivity disorder

www.ahrq.gov 9
(ADHD) in children. They will address two important

types of errors that occur in the management of ADHD:

failure to detect comorbid conditions and failure to

respond to adverse effects of ADHD medications. 

• Mining Complex Clinical Data for Patient Safety

Research; Grant No. R18 HS11806. Researchers are

developing an infrastructure to support automated

surveillance of errors by using a natural language

processor called MedLEE to code the information

contained in patients’ electronic medical records to

detect and characterize medical errors. Using a clinical

repository with 10 years of data on approximately 2

million patients, they will incorporate the system into a

hospital’s current events surveillance program and assess

its impact on error detection. 

• Informatics Tools to Reduce Warfarin Errors; Grant No.

R18 HS11804. This project will create clinical

informatics tools specifically designed to reduce the

incidence of warfarin dosing errors in hospitalized

patients who are taking this medication for the first

time. Researchers will modify a program that predicts

warfarin dosing requirements along with a program that

identifies potential drug-drug interactions. The

investigators will also evaluate the feasibility of using

these informatics tools in routine hospital practice. In

addition, they plan to make them widely available at no

cost for public use.

• Using Prospective Minimum Data Set Data to Enhance

Resident Safety; Grant No. R18 HS11869. This research

project will determine whether preventable adverse

outcomes for the frail elderly population in long-term

care settings can be avoided by using computers to alert

nursing and other staff to the likelihood that a problem

such as falls, pressure ulcers, and urinary tract infections

will occur. They will also identify resident-specific risk

factors that are likely to cause an adverse outcome and

target these risk factors for preventive interventions. 

• Impact of Electronic Prescribing on Medication Errors;

Grant No. R18 HS11868. This study will assess the

baseline medication error rate in an urban pediatric

emergency department and clinic. Researchers will also

examine the effect of handheld electronic prescription

writing on prescribing practices and medication error

rates.

• Identifying and Reducing Errors with Surgical

Simulation; Grant No. R18 HS11866. This research

project will use state-of-the-art simulation tools to train

otolaryngology physicians. Through the use of these

simulation tools, physicians will be able to practice

surgical procedures without exposing patients to the

potential risk of having their surgery performed by an

inexperienced surgeon. Data from the program will be

collected into a central database and used for outcomes

analysis. Technical errors and “near misses” will be

identified, quantified, and analyzed. This information

will be used to improve physician training and to

monitor ongoing performance. 

• Pharmacist Technology for Nursing Home Resident

Safety; Grant No. R18 HS11835. This study will use

the Geriatric Risk Assessment Minimum Data Set Med

Guide (GRAM), a clinical tool to alert medication

prescribers and nursing staff to information that can

reduce the threat to patient safety associated with

adverse drug events in nursing homes. The GRAM

software helps evaluate the complex medication

regimens of older patients, incorporates patient

assessment data for monitoring medication therapy, and

facilitates inclusion of recommendations in the care plan

to prevent medication-related problems. Researchers

will examine the extent to which the GRAM clinical

tool reduces the incidence of delirium, falls, and

hospitalizations due to adverse drug events and will

determine the impact the GRAM software has on the

efficiency, productivity, workload, and job satisfaction of

pharmacists and nursing facility staff.

• Linking User Error to Lab and Field Study of Medical

Informatics; Grant No. R18 HS11816. This project will

explore the relationship among human, machine, and

environmental factors associated with the operation of

infusion devices in clinical settings. The project will

identify and characterize properties of infusion devices,

environmental conditions, and problems in operator

cognition that promote “user error.” 

• HIV Treatment Error Reduction Using a Genotype

Database; Grant No. R18 HS11800. This project will

implement and evaluate an automated computerized

decision support system. The system will integrate

patient-specific HIV genotype information with

corresponding medication data within an electronic

10 www.ahrq.gov
www.ahrq.gov 11

medical record system to improve antiretroviral drug

selection, reduce prescribing errors, prevent the

development of drug resistance, and improve overall

quality of care. 

Conclusion

Medical informatics is one of many important components

necessary to improve the quality of health care in the

United States. Research funded by AHRQ over the past 30

years has given clinicians solutions to many problems they

face in patient care. It has covered a wide range of topics,

including the electronic medical record system, access to

current information, clinical reminders, clinical decision

support, electronic communication, patient education and

self-management of chronic disease, and methods for

identifying a bioterrorist attack. AHRQ remains committed

to supporting research in medical informatics, including

continued support of new and innovative technologies,

information/knowledge management, improved

communication between patients and providers, shared

decisionmaking, identifying and overcoming barriers to the

use of computers in health care, and new challenges posed

by the threat of bioterrorism. 

For more information

For further information on medical informatics at the

Agency for Healthcare Research and Quality, please contact

Eduardo Ortiz, M.D., M.P.H., at 301-594-6236 or

eortiz@ahrq.gov.
12 www.ahrq.gov

AHRQ-Funded Research on Medical Informatics

• Demonstrating Computer Support Impact on AIDS Patients, University of Wisconsin-Madison: This study examined the effects

of CHESS (Comprehensive Health Enhancement Support System, a patient-centered, computer-based support system) on the

health care costs and quality of care of HlV-infected men and women. 

• Effect of Computer Feedback on Physician Test Ordering, Indiana University: This project tested the effect of patient-specific

computer feedback on physicians’ test-ordering practices. 

• Variance in Medical Decisions: Causes and Cures, Indiana University: This study examined the effects of three informational

interventions (newsletters, reports comparing an individual physician with his or her peers, and personal contact by faculty

members) in terms of changes in physicians’ medical decisions. 

• Assessment of Technology Use Via a Computerized Ordering System, Indiana University: This study developed a

microcomputer network for ordering by physicians of all tests and treatments on the inpatient medicine service.

• Computerized National Chronic Disease Databank System, Stanford University: This project established a pilot rheumatic

disease computer data bank network (Arthritis, Rheumatism and Aging Medical Information System, or ARAMIS) that pooled

clinical data between institutions and institutional studies, allowed rapid access to large quantities of clinical data, and

provided computer consultation and clinical decision procedures based on these data. 

• Assessment of Technology in Chronic Disease, Stanford University: This project utilized ARAMIS, a successful national chronic

disease data bank system, to develop a systematic technology assessment program in rheumatic disease. 

• Clinical Applications of an Expert System, LDS Hospital: This project developed an antibiotic consultant for the Health

Evaluation through Logical Processing (HELP) hospital information system.

• Evaluation of a Computerized Infectious Disease Monitor, LDS Hospital: This study demonstrated the effectiveness of using a

computerized infectious disease monitor to minimize the inappropriate use of prophylactic antibiotics, optimize the use of

therapeutic antibiotics, and detect the presence of nosocomial infections. 

• Hospital Computer Project, Massachusetts General Hospital: This research project developed the Computer Stored Ambulatory

Record (COSTAR), a totally integrated computer-based information system that supported all the medical care, financial, and

administrative needs of an ambulatory care organization. 

• Computer-Based Access to Guidelines for Clinical Care, Massachusetts General Hospital: This study developed, implemented,

and evaluated a computer-based system that provided physicians and nurses access to clinical guidelines of care for the

purpose of learning and consultation. 

• Bioterrorism: Automated Decision Support and Clinical Data Collection, Boston Children’s Hospital: This project is developing

a prototype database and Web site to facilitate clinician reporting of trends reflecting possible bioterrorist events. 

• Using Information Technology to Improve Clinical Preparedness for Bioterrorism, MPC Corporation-University of

Pittsburgh/Carnegie Mellon University: This project is developing the Real-time Outbreak and Disease Surveillance (RODS)

system to provide early warning of infectious disease outbreaks possibly caused by an act of bioterrorism.

• Innovative Approaches to Training Clinicians for Bioterrorist Attacks: Online Modules, University of Alabama-Birmingham: This

project has developed interactive Web-based training modules to teach health professionals how to address varied biological

agents, including anthrax, smallpox, botulism, tularemia, viral hemorrhagic fever, and plague.
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www.ahrq.gov 13
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Press release date Feb. 23, 2001.

* AHRQ-funded/sponsored research

14 www.ahrq.gov
U.S. Department of

Health and Human Services

Public Health Service

Agency for Healthcare Research and Quality

2101 East Jefferson Street, Suite 501

Rockville, Maryland 20852

www.ahrq.gov

AHRQ Pub. No. 02-0031

June 2002

Previous issues of Research in Action are available for free from the AHRQ Publications Clearinghouse: 1-800-358-9295.

Please specify the AHRQ publication number when you call.

Issue Title Publication Number

5 Expanding Patient-Centered Care to Empower Patients and AHRQ 02-0024

Assist Providers

4 Managing Osteoarthritis: Helping the Elderly Maintain Function AHRQ 02-0023

and Mobility

3 Preventing Disability in the Elderly With Chronic Disease AHRQ 02-0018

2 Improving Care for Diabetes Patients Through Intensive AHRQ 02-0005

Therapy and a Team Approach

1 Reducing and Preventing Adverse Drug Events To Decrease AHRQ 01-0020

Hospital Costs