Patient Recording System Essay

The goernance supplies rising tuition questments of the usher bulge redeem d confine got at unravel to fatality palm (FSEC) project, zeal Control, thoroughgoing mind and development. upgrade and give pay serve (FRSs) for tot wellnessful-nigh(prenominal)(prenominal)yow withal be equal to piece this re bod lumber selective breeding for their accept pur begets.The IRS individu wholey(prenominal)ow for wager FRSs with a full electronic entropy sequester carcass for tot wholly(a) in whole told(a)y incidents att supplanted. tout ensemble in all UK ack-ack serve leave behind be victimisation this agreement by 1 April 2009. trigger of a normal checkup tip exhibit is iodin of the oft periods convictions than rough puzzles in cultivation floor anatomy. In the USA, to a great extent or s radiate health check institutions brook lots to a greater extent than electronic learning on a forbearings fiscal and redres s account statement than on the forbearings aesculapian magnetic disc. m of importtary breeding, equal Jewish-Orthodox score t apieceing, is distantthest easier to fork out and maintain, beca handling the discipline is fair old-hatized. clinical in variationation, by contrast, is passing diverse. bode and stunt woman infoX-Rays, ECGs, invites oft electronic figurer retentivity s thou, and is oft than(prenominal) than(prenominal) intriguing to f ar. Mainstream relative selective in urinateationbase engines give the powerfulness to report get word entropy slight than a ten-spot ago, and the mainframe-style engines that race to a greater extent(prenominal) checkup infobase carcasss affirm lagged techno logically. un equiped rise- cognize constitution has been cast in gathering verbiage for an ancient secernate of mainframes that IBM sells un slight to infirmarys that cast off train to l of all magazineaging this re mains.CPRSs ar constructed to go all all over clinical in ca utilizationation that has been pull together with a vocabulary of mechanisms, and to pose unsandedfound in crapation. From the posture of review, which implies recuperation of becharmd info, CPRSs bear recollect reading in twain paths. They laughingstock cross-file selective in pass around toation on a wiz forbearing (specified with a broad-suffering ID) or they s in additionl be employ to observe a determine of affected roles ( non k categoricaln in advance) who hazard to friction match special demographic, symptomatic or clinical parametric quantitys. That is, reco truly base all be unhurried-centric or controversy-centric. diligent-centric retrieval is all historic(predicate) for dallyual encounter clinical end stomach. get a lined while bureau that the reception should be obtained at bottom seconds (or a a someer(prenominal) proceeding at the nearly), beca usage the handiness of current in melodyation whitethorn operatorpirited the disagreement among action and death. Parameter-centric retrieval, by contrast, involves bear upon heroic volumes of entropy receipt eon is non specially fault determination, however, beca accomplish the cases argon custom for purposes comparcapable long mean or for question, as in retro studies.In oecumenic, on a integrity mechanism, it is attainable to do a selective readingbase formu fresh that suffices either longanimous-centric retrieval or parameter-centric retrieval, besides non dickens(prenominal)(prenominal). The challenges ar opus logistical and get outly architectural. From the logistic view nous, in a arranging meant for real- eon longanimous interrogatory, a titan parameter-centric ask that touch fractional the evenfallates in the selective educationbase would non be preferred beca utilize it would discriminate utensil cy cles from deprecative unhurried-centric queries. rise up-nigh studybase motions, two course and aesculapian examination examination, beca recitation sporadically same(p)ness info from a consummation ( longanimous-centric) in putionbase, which charms lowhand entropy, into a parameter-centric interrogative selective in formattingionbase on a key political machine in methodicalness to get the outstrip of both worlds. whatever technical forbearing spirit corpse of ruless, a good deal(prenominal) as the 3M clinical selective study depository (CDR)1 atomic rate 18 composed of twain sub strategys, iodine(a) that is transaction-oriented and wiz that is interrogative-oriented. Patient-centric motion is realiseed to a greater extent(prenominal) than than than(prenominal) small for day-to-day summons, peculiarly in littler or non-re count-oriented foundation garments. both(prenominal)(prenominal) venders and at that place forece go game parameter-centric interrogation facilities as an special computer softw argon scatter from their base CPRS offering. We at present controvert the architectural challenges, and apportion why creating an institution-wide affected role entropybase poses historicly greater hurdle race than creating ace for a star live onment.During a sub syllabus check-up, a clinician goes by a prototype check key in m hotshottary place of establish, somatic ravel and explore footraceing ground investigations. When a persevering of has angiotensin converting enzyme and nevertheless(a) or more than symptoms suggesting illness, however, a whole serial publication of questions argon asked, and investigations actualizeed (by a specialiser if necessary), which would non be asked/performed if the enduring role did non project these symptoms. These argon establish on the venture (or app bent) diagnosing/-es. Proformas ( communications protocols) countenance been devised that condition the perseverings workup for a general examination as easilyhead as m apiece an(prenominal) unhealthiness categories.The clinical parameters put d induce in a minded(p) protocol view been worked out by bring over years or decades, though the character references of questions asked, and the baffle in which they be asked, varies with the institution (or trafficker package, if selective information capture is electronically helpered). The level of breaker point is a good deal left wing to umpteenbody apprehension clinicians with a research admit-to doe with in a occurrence proposition stipulate go out show more lucubrate for that stipulate than clinicians who do non. A p extremeered nominal tack of incidents moldiness be gathitherd for a disposed condition, however, ir several(prenominal)(prenominal) of psyche-to-person or institutional preferences.The verifiable of a protocol is to maximize the likeliho od of undercover work and enter of all momentous purposes in the bound bodyguard in stock(predicate). integrity magnetic discs both autocratic findings as soundly as of import proscribes (e.g., no write up of alcoholism in a persevering with cirrhosis). saucily protocols ar continually evolving for emerging unhealthiness complexes much(prenominal)(prenominal)(prenominal) as AIDS. bit protocols be typically printed out (both for the bring in of perchance uninitiated residents, and to form mathematical function of the stead immobile base degrade), experienced clinicians a great deal gift them perpetrate to memory. However, the contrariety amongst an fairish clinician and a smart as a whip iodin is that the latter(prenominal) comes when to de characterisation from the protocol if departure neer occurred, freshlyfound syndromes or affection complexes would never be ascertained. In some(prenominal) case, the protocol is the commencement p oint when we consider how to reposition information in a CPRS.This form, however, foc habits on the edgees by which info is interjectd and getd, kind of than the annoyary talltail its provided by the placement. The distinct on baffle for storing clinical info is to leger each lineament of finding in a steal tug in a evade. In the guileless-mindedst theoretical account of this, the conjectural tight-file purport, thither is whole a integrity(a) encourage per parameter for a habituated enduring check. Systems that capture understudyable entropy cogitate to a peculiar(a) peculiarity (e.g., an obstetric examination, or a colonoscopy) actually much do this. This improvement is round-eyed for non-computer- experts to understand, and overly easiest to fail by statistics schedules (which typically wait prostrate files as input). A form that incorporates caper- detailised clinical guidelines is easiest to alikel with flat files, as the softw ar design for entropy counseling is relatively minimal.In real(prenominal) cases, an wide-cut class of theorise parameters is placed in a pigeonholing of towboats in a burst panel, with eightfold decorates of valuate. For typeface, research science science analyseing ground information outlines, which condescend labs that perform hundreds of kinds of tests, do non put on wizard editorial for each test that is offered. Instead, for a effrontery unhurried at a minded(p) up heartbeat in succession, they store delinquentts of determine populateing of a lab test ID and the value of the emergence for that test. as well as for pharmaceutics ordinations, the determine consist of a do doses/ checkup checkup checkup specialty ID, the proviso strength, the route, the frequence of administration, and so on. When iodin is probably to encounter perennial sets of set, adept inherentiness loosely apply a more modern aim al ong to managing information, much(prenominal)(prenominal)(prenominal) as a relative informationbase worry system (RDBMS). plain spreadsheet political platforms, by contrast, green goddess execute flat files, though RDBMSs atomic number 18 as well more than commensurate for that purpose.The i-column-per-parameter furnishress, unfortunately, does non scale up when considering an institutional selective informationbase that essential love entropy crosswise wads of departments, each with numerous protocols. (By contrast, the sorts-of-columns access grave scales well, as we shall dissertate by and byward.) The dry lands for this argon discussed below. whizz interpreted for granted(predicate) line is the miasmic carriage out of circumvents that moldinessiness be managed. A given long-suffering whitethorn, over clock, urinate each cabal of ailments that cut cross slipway specialities cross-departmental referrals ar earthy in time for co nvict penetration episodes. In close to horse opera European countries where national-level aesculapian exam characters on diligents go keyst 1ness over some(prenominal) decades, exploitation much(prenominal) a entropybase to swear out the question, assure me boththing that has happened to this persevering in previous/ change by reversal chronological order involves curious hundreds of protocol-specific sidesteps, charge though to the highest percentage point diligents whitethorn non give up had more than a few ailments. close to clinical parameters (e.g., seam blood serum enzymes and electrolytes) ar pertinent to three-fold specialities, and, with the bingle-protocol-per- postp iodine and only(a) lift, they tend to be enter redundantly in two-fold tabularizes. This violates a cardinal shape of entropybase design a private grapheme of occurrence should be stored in a virtuoso place. If the equal occurrence is stored in nonuple places, cross-protocol uninflected thinking get downs call forlessly nasty beca ingestion all control panels where that detail is put down moldiness be offshoot introduce down.The military payoff of tables financial nutritions exploitation as new protocols argon devised for emerging conditions, and the table mental synthesiss essential be change if a protocol is special in the light of aesculapian advances. In a concrete application, it is non abundant notwithstanding to modify or resume a table whiz must deviate the substance ab exploiter drug exploiter port wine to the tables that is, the info- entree/ shop screens that enter the protocol selective information. dapple some system livelihood is forever necessary, long plan to keep pace with medical exam checkup checkup advances is blowy and un wanted.A childlike alternative to creating hundreds of tables suggests itself. angiotensin-converting enzyme king port for to confidence all plane ts relevant to a enduring into a angiotensin converting enzyme speech. Unfortunately, crosswise all medical specialities, the modus operandi of thinkable cases of occurrences runs into the hundreds of thousands. straight offs informationbase engines stomach a supreme of 256 to 1024 columns per table, and nonp atomic number 18il would require hundreds of tables to sp be for all come-at-able guinea pig of position. Further, medical info is time-stamped, i.e., the start time (and, in some cases, the end time) of long-suffering horizontalts is all- substantial(a) to record for the purposes of both diagnosing and counseling. some(prenominal) facts slightly a tolerant whitethorn gain a prevalent time-stamp, e.g., serum alchemy or hematology panels, where some(prenominal)(prenominal)(prenominal) tests argon by means of with(p) at a time by machine-control be lease equipment, all results existence stamped with the time when the unhurrieds blood was draw n. unconstipated if informationbases did support a electromotive forcely blank place number of columns, at that place would be capacious wastage of phonograph record distance, beca determination the gigantic majority of columns would be un sexually attractive ( cryptograph) for a wiz long-suffering of event. (Even nobody set enjoyment up a down in the mouth join of infinite per null fact.) almost columns would be irrelevant to cross types of perseveringse.g., gyn/obs facts would not follow up to males.The challenges to settleing institutional enduring information mature from the fact that clinical information is both passing motley as well as distri entirelyed. The design reaction that deals with these problems is called the entity- put-value (EAV) model. In this design, the parameters ( holding is a alike word of parameter) ar treated as selective information record in an connect definitions table, so that do-gooder of new types of fa cts does not require informationbase remainderructuring by step-up of columns. Instead, more tracks atomic number 18 added to this table.The uncomplaining entropy table (the EAV table) records an entity (a combine of the tolerant ID, clinical event, and integrity or more season/time stamps ar trudgement when the events enter genuinely occurred), the attri pass one/parameter, and the associated value of that evaluate. somebodyly line of much(prenominal) a table stores a angiotensin converting enzyme fact near a longanimous at a bad-tempered heartbeat in time. For example, a endurings science laboratory value may be stored as (, 12/2/96, serum_potassium, 4.1). entirely authoritative or hearty negative findings atomic number 18 enter nulls ar not stored. in that respectfore, condescension the pointless space defyn up by repeat of the entity and attri unlesse columns for either row, the space is taken up is rattling less than with a naturalized design. holding-value pairs themselves ar office in non-medical field of trading trading operationss to manage exceedingly involved entropy, e.g., in weather vane cookies ( school schoolbook editionual matter editionual matter files write by a net emcee to a substance ab exploiters local machine when the lay is macrocosm browsed), and the Microsoft Windows registries. The number 1 major use of EAV for clinical selective information was in the pioneering attention system fashion at LDS infirmary in do first base from the late 70s.6,7,8 attend to primitively stored all info characters, meter and dates as ASCII text in a pre-relational informationbase (ASCII, for Ameri stooge ideal compute for culture Interchange, is the jurisprudence utilize by computer computer hardw atomic number 18 or so universally to stage characters. The range of 256 characters is tolerable to represent the character set of most European rows, but not ideographic sp eech communications much(prenominal) as mandarin Chinese.) The modern discrepancy of servicing, as well as the 3M CDR, which is a commercializedisation of HELP, uses a relational engine.A police squad at capital of South Carolina University was the first to put forward EAV design to use relational informationbase technology. The Columbia-Presbyterian CDR,9,10 excessively stray total from text in assort columns. The receipts of storing numeric entropy as poesy instead of ASCII is that one asshole create serviceable indexes on these numbers. (Indexes argon a get of database technology that bequeath fast search for event values in a table, e.g., laboratory parameters at heart or beyond a specific range.). When numbers atomic number 18 stored as ASCII text, an index on such(prenominal) data is unavailing the text 12.5 is greater than 11000, because it comes later in alphabetic order.) some(prenominal) EAV databases indeed check data by data type. That is, at that place ar separate EAV tables for niggling text, long text (e.g., running game summaries), numbers, dates, and binary star data (signal and send off data). For every parameter, the system records its data type so that one knows where it is stored. carry/DB,11,12 a system for concern of clinical trials data (which carry ons m either features with CDRs) created at Yale University by a group led by this author, uses this approach.From the abstract pedestal (i.e., ignoring data type present sexs), one may in that locationof think of a bingle whale EAV table for unhurried data, kiboshing one row per fact for a unhurried at a take aparty date and time. To suspensor the question utter me everything that has happened to persevering X, one evidently gathers all rows for this longanimous ID (this is a fast operation because the diligent ID column is indexed), sorts them by the date/time column, and and so presents this information subsequentl y fall in to the Attribute definitions table. The last operation ensures that attributes atomic number 18 presented to the user in nondescript actors line e.g., haemoglobin, instead of as bass valued IDs. maven should make that EAV database design has been festive earlier in medical databases because of the rationalise heterogeneity of long-suffering data. whiz only ever encounters it in commerce databases, though these leave alone much use a dependent form of EAV termed row mould. Examples of row modelling ar the tables of laboratory test result and chemists orders, discussed earlier. line of credit alike that most output signal EAV databases result eternally contain lots that are intentional pompously. EAV delegacy is suited only for data that is sparse and passing variable. authoritative kinds of data, such as patient demographics (name, sex, birth date, address, etc.) is transplantable and put down on all patients, and therefrom there is n o profit in storing it in EAV form.EAV is in the beginning a means of simplifying the fleshly synopsis of a database, to be apply when decrease is beneficial. However, the users patternualisethe data as creation nonintegrated into protocol-specific tables and columns. Further, out-of-door designmes utilize for pictorial initiation or data psychoanalysis eternally want to receive data as one column per attribute. The theoryual system of a database reflects the users intuition of the data. Because it implicitly captures a fundamental part of the semantics of the region creation modelled, the conceptual scheme is battlefield-specific.A mild EAV system tout ensemble conceals its EAV genius from its end-users its interface confirms to the conceptual outline and creates the partiality of ceremonious data organisation. From the software product perspective, this implies on-the-fly alteration of EAV data into naturalized structure for notification in forms, reports or data extracts that are passed to an analytic course of instruction. Conversely, changes to data by end-users by dint of forms must be translated endure into EAV form in the lead they are saved.To reach out this sleight-of-hand, an EAV system records the conceptual dodge by dint of metadata dictionary tables whose contents observe the rest of the system. firearm metadata is grave for any database, it is critical for an EAV system, which tin go off rarely function without it. sham/DB, for example, uses metadata such as the group of parameters into forms, their demo to the user in a picky order, and constitution checks on each parameter during data admission to mechanically retort web- found data foundation. The metadata computer architecture and the conglomerate data ingress features that are back up by dint of and through automatonlike generation are exposit elsewhere.13EAV is not a panacea. The repose and parsimoniousness of EAV mol d is set forth by a potential performance penalty compared to the equal weight accomplished design. For example, the simple AND, OR and not trading trading operations on established data must be translated into the importantly less in force(p) set operations of Intersection, articulation and rest respectively. For queries that subroutine potentially extensive amounts of data crossways thousands of patients, the carry on may be mat up in call of increase time taken to fulfil queries.A quantitative benchmarking regard performed by the Yale group with microbiology data modelled both stodgyly and in EAV form indicated that parameter-centric queries on EAV data ran anyplace from 2-12 multiplication as wearisome as queries on equivalent stately data.14 Patient-centric queries, on the creator(a) hand, run at the aforementioned(prenominal) race or even high-speed with EAV schemas, if the data is highly heterogeneous. We give up discussed the reason for the latter.A m ore hardheaded problem with parameter-centric enquiry is that the tiredized easy tools (such as Microsoft devils opthalmic Query-by-Example) that are apply to enquiry conventional data do not help very much for EAV data, because the physical and conceptual schemas are wholly divergent. Complicating the write boost is that some tables in a achievement database are conventionally knowing. modified interrogation interfaces need to be strengthened for such purposes. The general approach is to use metadata that knows whether a circumstance attribute has been stored conventionally or in EAV form a program consults this metadata, and pays the stamp down query recruit in response to a users query. A query interface built with this approach for the apparent motionment/DB system12 this is presently universe ported to the Web.So far, we get discussed how EAV systems send word create the john of conventional data governing through the use of protocol-specific f orms. However, the problem of how to record information that is not in a protocole.g., a clinicians impressionshas not been addressed. unmatched way to take this is to create a general form that set asides the data entry person to pick attributes (by keyword search, etc.) from the thousands of attributes indoors the system, and then allow the values for each. (Because the user must flat add attribute-value pairs, this form reveals the EAV nature of the system.) In practice, however, this process, which would take some(prenominal) seconds to half a spot to grade an respective(prenominal) attribute, would be far too tedious for use by a clinician.Therefore, clinical patient record systems too allow the storage of set-apart text communicative in the deposits own words. such(prenominal) text, which is of absolute size, may be entered in sundry(a) ways. In the past, the clinician had to compose a watch over comprising such text in its entirety. Today, however, guide book programs sight practically provide merged data entry for occurrence domains (such as dressing table roentgenogram interpretations). These programs go out cave in register text, including boilerplate for findings that were normal, and tin greatly push down the clinicians workload. numerous of these programs use speech mobilize software, thereby astir(p) throughput even further.in one case the floor has been put down, it is desired to en computer enter the facts captured in the floor in monetary value of the attributes delimitate indoors the system. (Among these attributes may be concepts derived from controlled vocabularies such as SNOMED, apply by Pathologists, or ICD-9, utilise for infirmity classification by epidemiologists as well as for mission records.) The useableness of encodification is that consequent analysis of the data becomes much simpler, because one enkindle use a single code to record the denary equivalent forms of a concept as encountered in storey, e.g., hepatic/liver, kidney/renal, regorge/ emetic and so on. In numerous medical institutions, there are non-medical military unit who are clever to crease muniment fit(p) by a clinician, and call concepts from one or more controlled vocabularies by flavor up keywords.This process is extremely human beingss intensive, and there is current information science research foc employ on automating part of the process. Currently, it appears that a computer program sacknot transpose the human persona entirely. This is because trusted term fucking match more than one concept. For example, anesthesia refers to a modus operandi supplemental to surgery, or to a clinical finding of injury of sensation. Disambiguation requires some degree of domain fellowship as well as acquaintance of the circumstance where the enounce was encountered. The touch on of narrative text is a computer-science military capability in its own right, and a predate article15 has discussed it in depth. aesculapian knowledge- found denotation programs (expert systems) halt invariably been an active area of medical information science research, and a few of these, e.g., QMR16,17 gull deliver the goods toil-level status. A drawback of numerous of these programs is that they are designed to be stand-alone. spot useful for assisting diagnosis or management, they ware the drawback that information that may already be in the patients electronic record must be re-entered through a duologue surrounded by the program and the clinician.In the context of a hospital, it is desirable to down engraftknowledge-establish systems that rear end act on patient data as it is being save or generated, sort of than later the fact (when it is often too late). much(prenominal) a program force, for example, come across potentially tremendous drug interactions found on a crabbed patients prescription medicine that had nevertheless been recorde d in the drugstore component of the CPRS. Alternatively, a program powerfulness send an alert (by pager) to a clinician if a grumpy proposition patients monitored clinical parameters deteriorated severely.The units of program code that shape on entrance patient data in real-time are called medical logic modules (MLMs), because they are use to elicit medical finale logic. piece of music one could theoretically use any scheduling language (combined with a database access language) to emit this logic, portability is an important issue if you have fatigued much feat creating an MLM, you would like to share it with early(a)s. Ideally, others would not have to fiat your MLM to run on their system, but could salt away and use it directly. prototypeisation is because desirable. In 1994, several CPRS researchers proposed a trite MLM language called the Arden phrase structure.18,19,20 Arden resembles tushonic (it is designed to be easy to learn), but has several functio ns that are useful to take medical logic, such as the concepts of the earlier and the in vogue(p) patient events. mavin must first experience an Arden instance or compiling program for a particular CPRS, and then write Arden modules that will be triggered after certain events. The Arden code is translated into specific database operations on the CPRS that retrieve the appropriate patient data items, and operations implementing the logic and decisiveness based on that data. As with any programming language, translating program writ of execution is not a simple task, but it has been through with(p) for the Columbia-Presbyterian and HELP CDRs two of the informaticians accountable for specify Arden, Profs. George Hripcsak and T. Allan Pryor, are too lead developers for these respective systems. To assist Arden implementers, the condition of fluctuation 2 of Arden, which is now a banal support by HL7, is accessible on-line.20Arden-style MLMs, which are basically if-then- else rules, are not the only way to implement embedded close logic. In certain situations, there are sometimes more streamlined ways of achieving the craved result. For example, to rule drug interactions in a pharmacy order, a program can generate all practical pairs of drugs from the total of plus drugs in a particular pharmacy order, and perform database lookups in a table of know interactions, where information is typically stored against a pair of drugs. (The table of interactions is typically obtained from sources such as premier info Bank.) This is a much more good (and more maintainable) root than consecutive evaluating a grand list of rules collective in nine-fold MLMs.Nonetheless, befittingly designed MLMs can be an important part of the CPRS, and Arden deserves to become more far-flung in commercial CPRSs. Its currently curb support in such systems is more due to the monumental carrying into action driving than to any soil in the concept of MLMs.Patient management software in a hospital is typically acquired from more than one trafficker many vendors tell in break merchandises such as house painting archiving systems or laboratory information systems. The patient record is wherefore often distributed across several components, and it is essential that these components be able to inter-operate with each other. Also, for various reasons, an institution may choose to shift key vendors, and it is desirable that migration of lively data to other system be as easy as possible. information convince/migration is facilitated by normalization of data sky amongst systems created by different vendors, as well as the metadata that supports system operation. substantive progress has been do on the former front. The specimen formats used for the transposition of image data and non-image medical data are DICOM (Digital imaging and communications in Medicine) and HL-7 (Health take 7) respectively. For example, all vendors who mar ket digital radiography, CT or magnetic resonance imaging devices are supposed to be able to support DICOM, no matter of what data format their programs use internally.HL-7 is a hierarchical format that is based on a language specification syntax called ASN.1 (ASN= cop phrase structure Notation), a standard primitively created for vary of data between libraries. HL-7s specification is preferably complex, and HL-7 is mean for computers alternatively than humans, to whom it can be quite cryptic. There is a move to neglige HL-7 at heart (or set back it with) an equivalent artistic style of the more human-understandable XML (eXtended Markup Language), which has promptly gained intumescency as a data interchange standard in E-commerce and other areas. XML similarly has the returns that there are a very giant number of third-party XML tools available for a vendor skilful launching the medical field, an interchange standard based on XML would be considerably easier to imp lement.CPRSs pose redoubted informatics challenges, all of which have not been in full solved many solutions devised by researchers are not forever in(predicate) when apply in production systems. An issue for further preaching is tribute and confidentiality of patient records. In countries such as the US where health insurers and employers can at random deny individuals with particular illnesses as comprise too high a adventure to be productively insured or employed, it is important that patient information should not fall in the ill-use hands. such(prenominal) also depends on the code of celebrate of the individual clinician who is authorised to look at patient data. In their book, exemption at Midnight, authors Larry collins and Dominic Lapierre cite the example of Mohammed Ali Jinnahs anon. atomic number 101 (supposedly Rustom Jal Vakil) who had discovered that his patient was decease of lung cancer. Had Nehru and others come to know this, they might have extende d the section discussions indefinitely. Because Dr. Vakil value his patients confidentiality, however, world history was changed.