The IsraeLi healthcare system has undergone major processes for the adoption of health information technologies (HIT), and enjoys high Levels of utilization in hospital and ambulatory care. Coding is an essential infrastructure component of HIT, and ts purpose is to represent data in a simplified and common format, enhancing its manipulation by digital systems. Proper coding of data enables efficient identification, storage, retrieval and communication of data. UtiLization of uniform coding systems by different organizations enables data interoperability between them, facilitating communication and integrating data elements originating in different information systems from various organizations. Current needs in Israel for heaLth data coding include recording and reporting of diagnoses for hospitalized patients, outpatients and visitors of the Emergency Department, coding of procedures and operations, coding of pathology findings, reporting of discharge diagnoses and causes of death, billing codes, organizational data warehouses and national registries. New national projects for cLinicaL data integration, obligatory reporting of quality indicators and new Ministry of Health (MOH) requirements for HIT necessitate a high Level of interoperability that can be achieved only through the adoption of uniform coding. Additional pressures were introduced by the USA decision to stop the maintenance of the ICD-9-CM codes that are also used by Israeli healthcare, and the adoption of ICD-10-C and ICD-10-PCS as the main coding system for billing purpose. The USA has also mandated utilization of SNOMED-CT as the coding terminology for the ELectronic Health Record problem list, and for reporting quality indicators to the CMS. Hence, the Israeli MOH has recently decided that discharge diagnoses will be reported using ICD-10-CM codes, and SNOMED-CT will be used to code the cLinical information in the EHR. We reviewed the characteristics, strengths and weaknesses of these two coding systems. In summary, the adoption of ICD-10-CM is in line with the USA decision to abandon ICD-9-CM, and the Israeli heaLthcare system could benefit from USA heaLthcare efforts in this direction. The Large content of SNOMED-CT and its sophisticated hierarchical data structure will enable advanced cLinicaL decision support and quality improvement applications.

BACKGROUND:Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease. The Computer-based Clinical Decision Support System provides an opportunity t close these gaps. OBJECTIVES:To study the impact of computerized intervention on secondary prevention of CAD. METHODS:The CDSS was programmed to automatically detect patients with CAD and to evaluate the availability of an updated lipoprotein profile and treatment with lipid-lowering drugs. The program produced automatic computer-generated monitoring and treatment recommendations. Adjusted primary clinics were randomly assigned to intervention (n=56) or standard care arms (n=56). Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment. Compliance and lipid levels were monitored. The study group comprised all patients with CAD who were alive at least 3 months after hospitalization. RESULTS:Follow-up was available for 7448 patients (median 19.8 months, range 6-36 months). Overall, 51.7% of patients were adequately screened, and 55.7% of patients were compliant with treatment to lower lipid level. In patients with initial low density lipoprotein >120 mg/dl, a significant decrease in LDL levels was observed in both arms, but was more pronounced in the intervention arm: 121.9 +/- 34.2 vs. 124.3 +/- 34.6 mg/dl (P < 0.02). A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs, 37% vs. 40.9% (P < 0.001). CONCLUSIONS:This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines, presenting a major obstacle to implementing effective secondary prevention. Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation.

BACKGROUND Syncope is a common clinical problem that often remains undiagnosed despite extensive and expensive diagnostic evaluation. OBJECTIVES To assess the diagnostic evaluation, costs and prognosis of patients hospitalized for syncope in a tertiary referral center according to discharge diagnosis. METHODS We retrospectively reviewed the medical records of patients with a diagnosis of syncope discharged from a tertiary referral center in 1999. In addition, mortality data were obtained retrospectively a year after discharge for each patient. RESULTS The study group comprised 376 patients. Discharge etiologies were as follows: vasovagal 26.6%, cardiac 17.3%, neurological 4.3%, metabolic 0.5%, unexplained 47.3%, and other 4%. A total of 345 patients were admitted to the internal medicine department, 28 to the intensive cardiac care unit, and 3 to the neurology department. Cardiac and neurological tests were performed more often than other tests, with a higher yield in patients with cardiac and neurological etiologies respectively. The mean evaluation cost was 11,210 +/- 8133 NIS, and was higher in the ICCU than in internal medicine wards (19,210 +/- 11,855 vs. 10,443 +/- 7314 NIS, respectively; P = 0.0015). Mean in-hospital stay was 4.9 +/- 4.2 days, which was longer in the ICCU than in medicine wards (7.2 +/- 5.6 vs. 4.6 +/- 3.5 days, respectively; P = 0.024). Short-term mortality rates (30 days after discharge) and long-term mortality rates (1 year after discharge) were 1.9% and 8.8% respectively, and differed according to discharge etiology. LTM rates were significantly higher in patients discharged with cardiac, neurological and unknown etiologies (not for vasovagal), compared with the general population of Israel (1 year mortality rate for the age-adjusted [65 years] general population = 2.2%). The LTM rate was higher in patients discharged with a cardiac etiology than in those with a non-cardiac etiology (15.4% vs. 7.4%, P = 0.04). Higher short and long-term mortality rates were associated with higher evaluation costs. CONCLUSIONS Hospitalization in a tertiary referral center for syncope is associated with increased mortality for most etiologies (except vasovagal), cardiac more than non-cardiac. Despite high costs of inpatient evaluation, associated with more diagnostic tests, longer in-hospital stay and higher mortality rates, nearly half of the patients were discharged undiagnosed. Outpatient evaluation should be considered when medically possible.

Background: Depressed heart rate variability (HRV) is a risk factor for mortality in post myocardial infarction (MI) Patients. We evaluated the prognostic role of ultra short-term HRV calculated from a 10 second rhythm strip of standard 12 leads ECG.

Human Factors research on warning systems may have relevance beyond the specific domain of operators receiving warnings about potential problems in technological systems. We present an analysis of physicians' responses to letters generated by an automated decision support system in terms of findings in the human factors literature on warnings. The automated system mails reminders to primary medical teams about patients requiring screening or lipid-lowering drugs. The effectiveness of the system depends, among other factors, on physicians' responses to the reminders. Some properties of the reminder letter have parallels in warning systems. They should affect physicians' responses as they affect the responses of operators of technological systems. We report the results of preliminary analyses of data after a 16 months follow-up of 6,571 patients. The compliance rate to recommendations in the letters in the intervention group, in which physicians receive reminder letters, was significantly higher than in the control group. Physicians in the control group were found to be less compliant as the number of their patients requiring the medical care grows. In contrast, physicians in the intervention group, who received the reminder letters, maintained similar levels of compliance irrespective of the number of patients who required their care. Thus the letters appear to provide valuable information for physicians who have to cope with more difficult patient populations.

Cardiovascular disease and breast cancer are the two main causes of mortality in women. Mammography as a screening test for breast cancer is recommended for all women from the age of 40 to 50 years. Mammographically detected breast arterial calcifications are currently considered an incidental finding without clinical importance, since they are not associated with an increased risk of breast cancer. However, recent studies have shown that breast arterial calcifications on mammograms have been associated with cardiovascular risk factors and atherosclerotic cardiovascular disease. These results suggest that breast arterial calcifications, detected during routine mammography, are a noteworthy finding that could be valuable in identifying asymptomatic women at increased cardiovascular risk.

Objective: To determine risk factors for maternal rehospitalization after term vaginal delivery. Study design: The study group consisted of all women who were rehospitalized following singleton vaginal deliveries during 1996-1998 (n = 194). The control group consisted of 427 women who were not rehospitalized during the same period. Results: The incidence of rehospitalization was 0.75% (194/25 885). Maternal chronic diseases, preterm contractions and pre-eclampsia rates were significantly higher among the study group as compared to the controls (25.3% vs. 8.4%, p < 0.001; 6.7% vs. 2.8%, p = 0.022; 9.3% vs. 4.9%, p = 0.037, respectively). Duration of labor was significantly longer in the study group as opposed to the controls (379 ± 406 min vs. 259 ± 276 min, p < 0.001). The rates of postpartum hemorrhage, blood transfusion and antibiotic treatment during delivery hospitalization were significantly higher among the study group (1.5% vs. 0.2%, p = 0.021; 4.6% vs. 0.7%, p < 0.001; 26.8% vs. 14.1%, p < 0.001, respectively). Using a forward logistic regression analysis, prolonged labor and blood transfusion during labor were found as independent risk factors associated with rehospitalization (OR 1.001, 95% CI 1.001-1.002, p = 0.001; OR 4.751, 95% CI 1.698-13.292, p = 0.003). In contrast, vertex presentation had a protective effect against rehospitalization (p = 0.027, OR 0.084, 95% CI 0.009-0.758). Conclusions: Blood transfusion and prolonged labor are independent risk factors for rehospitalization after term vaginal delivery. Special attention should be given during the early postpartum period to patients receiving blood transfusions and those with prolonged deliveries, in order to reduce rehospitalization rates.

Chronic diseases are a significant burden on western healthcare systems and national economies. It has been suggested that automated disease management for chronic disease, like diabetes mellitus (DM), improves the quality of care and reduces inappropriate utilization of diagnostic and therapeutic measures. We have designed a comprehensive DM Disease Management system for the Negev region in southern Israel. This system takes advantage of currently used clinical and administrative information systems. Algorithms for DM disease management have been created based on existing and accepted Israeli guidelines. All data fields and tables in the source information systems have been analyzed, and interfaces for periodic data loads from these systems have been specified. Based on this data, four subsets of decision support algorithms have been developed. The system generates alerts in these domains to multiple end users. We plan to use the products of this information system analysis and disease management specification in the actual development process of such a system shortly.

We investigated the efficacy of percutaneous coronary intervention (PCI) in coronary thrombotic lesions according to the timing of the procedure. Eighty-two patients who underwent immediate PCI (IPCI) were compared to 24 patients who underwent PCI 4.9 3 days after the diagnostic catheterization [delayed PCI (DPCI)]. DPCI was associated with a lower rate of thrombus-related angiographic events (4% versus 27%; p < 0.03), including coronary embolism (0% versus 7%; p = NS), no-reflow phenomenon (0% versus 8%; p = NS), acute closure (0% versus 10%; p = NS), stent thrombosis (4% versus 1%; p = NS) and residual thrombus (0% versus 17%; p = 0.03). No differences were seen in the hospital clinical outcome, including non-fatal myocardial infarction (4% versus 9%; p = NS), death (4% versus 0%; p = NS) or major bleeding (4% versus 3%). Delayed PCI after pharmacological treatment is a safe and efficient strategy of treatment for coronary thrombus.

Automatic alerting systems for key events in medical practice have been proven effective in improving the clinician's response to the event. Most of the systems described in current literature are hospital based, some in intensive care units. We designed a clinical alerting system that screens laboratory results of both hospitalized patients and most of Israel's Southern region ambulatory patients for critical results, using an integrative CDR and its interfaces to the hospital's laboratory information systems. New alerts can be defined and activated using a rule editor. Alerts are generated by screening all new laboratory results that are entered in to the CDR, by a decision engine. The alerts are dispatched to clinicians through a customizable preferred alerting device that can be either e-mail, fax or cellular phone SMS, and enables additional alerting devices as they become available. Clinicians may customize both the alerting method and the critical levels for alert generation, according to individual specific needs. We hope that this versatile and customizable alerting system will suite the needs of both the hospital and the community clinical staff. The system will be implemented and tested in the near future.

Background. We have developed an interdisciplinary problem list for use in the electronic patient record of our 4 medical/surgical ICUs. Previous experience in developing problem lists suggests that terminology should be familiar to clinicians, be based on current clinical practice and be developed with clinician input[l,2,31. Our goal was to develop a problem list that would be consistently used and updated by all clinicians in the critical care setting.

BACKGROUNDAssessment of quality of life has become an increasingly important aspect of the risk-benefit analysis of any therapeutic intervention, particularly in high-risk populations, such as the elderly.METHODSClinical outcomes of 147 consecutive patients older than 75 years undergoing valve surgery between 1992 and 1995 were reviewed. Long-term quality of life was assessed using a modified version of the Duke University Medical Outcomes Study system.RESULTSMean age was 79.3+/-4 years, range was 75 to 89 years, and 67% (99/147) were male. Preoperatively, 128 patients (87%) were in New York Heart Association (NYHA) functional class III/IV. Fifty-two percent (77/147) of the operations were nonelective. Concomitant coronary artery bypass grafting was performed in 69 patients (47%). Thirty-day hospital mortality was 7.5% (11/147). Mean follow-up for 98% (133/136) of hospital survivors was 30+/-13 months (range, 2 to 55 months). Actuarial survival at 55 months was 71+/-6%-equivalent to a general age-, race-, and gender-matched population reported in the Life Tables of the US National Center for Health Statistics. At the time of follow-up, 112 patients (96%) lived at home, 78% (91/116) defined their health between good to excellent, and 81% (93/114) stated that the operation improved their health status. Ninety-seven percent (112/116) were able to bathe and dress independently, 92% (104/113) could walk at least one block, and 88.5% (100/113) could climb at least one flight of stairs. Moderate to vigorous activities could be performed by 59.2% (67/113). Overall, at the time of follow-up, 81% (95/117) were in NYHA class I/II.CONCLUSIONIn a selected patient population, valve surgery in the elderly is associated with acceptable early morbidity and mortality. Long-term survival and quality of life are excellent. These facts strongly support the performance of these procedures in patients older than 75 years.