Computational biomedicine: a challenge for the twenty-first century

With the relentless increase of computer power and the widespread availability of digital patient-specific medical data, we are now entering an era when it is becoming possible to develop predictive models of human disease and pathology, which can be used to support and enhance clinical decision-making. The approach amounts to a grand challenge to computational science insofar as we need to be able to provide seamless yet secure access to large scale heterogeneous personal healthcare data in a facile way, typically integrated into complex workflows-some parts of which may need to be run on high performance computers-in a facile way that is integrated into clinical decision support software. In this paper, we review the state of the art in terms of case studies drawn from neurovascular pathologies and HIV/AIDS. These studies are representative of a large number of projects currently being performed within the Virtual Physiological Human initiative. They make demands of information technology at many scales, from the desktop to national and international infrastructures for data storage and processing, linked by high performance networks.

Health information technology impact on productivity

Managers work to achieve the greatest output for the least input effort, better balancing all factors of delivery to achieve the most with the smallest resource effort. Documentation of actual health information technology (HIT) cost savings has been elusive. Information technology and linear programming help to control hospital costs without harming service quality or staff morale. This study presents production function results from a study of hospital output during the period 2008-2011. The results suggest that productivity varies widely among the 58 hospitals as a function of staffing patterns, methods of organization, and the degree of reliance on information support systems. Financial incentives help to enhance productivity. Incentive pay for staff based on actual productivity gains is associated with improved productivity. HIT can enhance the marginal value product of nurses and staff, so that they concentrate their workday around patient care activities. The implementation of electronic health records (EHR) was associated with a 1.6 percent improvement in productivity.

Group profile management in ubiquitous healthcare environment

Nowadays, ubiquitous healthcare is of utmost importance in the patient-centric model. Furthermore, the personalization of ubiquitous healthcare services plays a very important role to make the patient-centric model a reality. The personalization of the ubiquitous healthcare services is based on the profiles of the entities participating in these services. In this paper, we propose a group profile management system in a ubiquitous healthcare environment. The proposed system is responsible for the dynamic creation of a group profile and its management.

Impact of the social networking applications for health information management for patients and physicians

Most social network users hold more than one social network account and utilize them in different ways depending on the digital context. For example, friendly chat on Facebook, professional discussion on LinkedIn, and health information exchange on PatientsLikeMe. Thus many web users need to manage many disparate profiles across many distributed online sources. Maintaining these profiles is cumbersome, time consuming, inefficient, and leads to lost opportunity. In this paper we propose a framework for multiple profile management of online social networks and showcase a demonstrator utilising an open source platform. The result of the research enables a user to create and manage an integrated profile and share/synchronise their profiles with their social networks. A number of use cases were created to capture the functional requirements and describe the interactions between users and the online services. An innovative application of this project is in public health informatics. We utilize the prototype to examine how the framework can benefit patients and physicians. The framework can greatly enhance health information management for patients and more importantly offer a more comprehensive personal health overview of patients to physicians.

Group-based and personalized care in an age of genomic and evidence-based medicine: a reappraisal

This article addresses the philosophical and moral foundations of group-based and individualized therapy in connection with population care equality. The U.S. Food and Drug Administration (FDA) recently modified its public health policy by seeking to enhance the efficacy and equality of care through the approval of group-specific prescriptions and doses for some drugs. In the age of genomics, when individualization of care increasingly has become a major concern, investigating the relationship between population health, stratified medicine, and personalized therapy can improve our understanding of the ethical and biomedical implications of genomic medicine. I suggest that the need to optimize population health through population substructure-sensitive research and the need to individualize care through genetically targeted therapies are not necessarily incompatible. Accordingly, the article reconceptualizes a unified goal for modern scientific medicine in terms of individualized equal care.

The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials

OBJECTIVE

The US Agency for Healthcare Research and Quality funded an evidence report to address seven questions on multiple aspects of the effectiveness of medication management information technology (MMIT) and its components (prescribing, order communication, dispensing, administering, and monitoring).

MATERIALS AND METHODS

Medline and 11 other databases without language or date limitations to mid-2010. Randomized controlled trials (RCTs) assessing integrated MMIT were selected by two independent reviewers. Reviewers assessed study quality and extracted data. Senior staff checked accuracy.

RESULTS

Most of the 87 RCTs focused on clinical decision support and computerized provider order entry systems, were performed in hospitals and clinics, included primarily physicians and sometimes nurses but not other health professionals, and studied process changes related to prescribing and monitoring medication. Processes of care improved for prescribing and monitoring mostly in hospital settings, but the few studies measuring clinical outcomes showed small or no improvements. Studies were performed most frequently in the USA (n=63), Europe (n=16), and Canada (n=6).

DISCUSSION

Many studies had limited description of systems, installations, institutions, and targets of the intervention. Problems with methods and analyses were also found. Few studies addressed order communication, dispensing, or administering, non-physician prescribers or pharmacists and their MMIT tools, or patients and caregivers. Other study methods are also needed to completely understand the effects of MMIT.

CONCLUSIONS

Almost half of MMIT interventions improved the process of care, but few studies measured clinical outcomes. This large body of literature, although instructive, is not uniformly distributed across settings, people, medication phases, or outcomes.

Provider and systems factors in diabetes quality of care

A gap exists in knowledge and the observed frequency with which patients with diabetes actually receive treatment for optimal cardiovascular risk reduction. Many interventions to improve quality of care have been targeted at the health systems level and provider organizations. Changes in several domains of care and investment in quality by organizational leaders are needed to make long-lasting improvements. In the studies reviewed, the most effective strategies often have multiple components, whereas the use of one single strategy, such as reminders only or an educational intervention, is less effective. More studies are needed to examine the effect of several care management strategies simultaneously, such as use of clinical information systems, provider financial incentives, and organizational model on processes of care and outcomes.

Technology-driven intervention to improve hypertension outcomes in community health centers

OBJECTIVES

To assess the impact of an electronic medical record (EMR) with clinical decision support (CDS) and performance feedback on provider adherence to guideline-recommended care and blood pressure (BP) control compared with a standard EMR alone.

STUDY DESIGN

Quasi-experimental with repeated measures.

METHODS

The study was conducted in a 4-site, federally qualified health center, Open Door Family Medical Centers, located in New York. The research team, Open Door leadership, providers, and staff developed and implemented a tailored multicomponent CDS system, which included a BP alert, a hypertension (HTN) order set, an HTN template, and clinical reminders. We extracted patient-level data for each encounter 17 months prior to implementation of the intervention (June 2007-October 2008) and 15 months post-intervention (April 2009-June 2010), from the EMR's data tables for all adult nonobstetric patients with a diagnosis of HTN (N = 3636).

RESULTS

Rates of HTN control were significantly greater in the post-intervention period compared with the baseline period (50.9% vs 60.8%; P <.001). Process measures, derived from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Guidelines, also improved significantly. Logistic regression with generalized estimating equations showed that patients were 1.5 times more likely to have controlled BP post-intervention than pre-intervention. Correlates of poor BP control were black race, higher body mass index, diabetes, female gender, income, and a greater number of prescribed antihypertensive medications.

CONCLUSIONS

Our findings suggest that health information technology that is implemented as part of a multicomponent quality improvement initiative can lead to improvements in HTN care and outcomes.

Electronic prescribing within an electronic health record reduces ambulatory prescribing errors

BACKGROUND

Health policy forces are promoting the adoption of interoperable electronic health records (EHRs) with electronic prescribing (e-prescribing). Despite the promise of EHRs with e-prescribing to improve medication safety in ambulatory care settings--where most prescribing occurs and where errors are common--few studies have demonstrated its effectiveness. A study was conducted to assess the effect of an e-prescribing system with clinical decision support, including checks for drug allergies and drug-drug interactions, that was integrated within an EHR on rates of ambulatory prescribing errors.

METHODS

In a prospective study using a nonrandomized, pre-post design with concurrent controls, 6 providers who used a commercial e-prescribing system were compared with 15 providers who remained paper-based from September 2005 through July 2008. Prescribing errors were identified by a standardized prescription and chart review.

RESULTS

Some 2,432 paper prescriptions at baseline and 2,079 prescriptions at one year were analyzed. Error rates for e-prescribing adopters decreased 1.5-fold--from 26.0 errors per 100 prescriptions at baseline (95% confidence interval [CI], 17.4-38.9) to 16.0 errors per 100 prescriptions at one year (95% CI, 12.7-20.2; p = .09). Error rates remained unchanged for nonadopters (37.3 per 100 prescriptions at baseline, 95% CI, 27.6-50.2, versus 38.4 per 100 prescriptions at one year, 95% CI 27.4-53.9; p = .54). Error rates for e-prescribing adopters were significantly lower than for nonadopters at one year (p < .001). Illegibility errors were high at baseline and eliminated by e-prescribing.

CONCLUSIONS

The preliminary findings from this small group of providers suggest that e-prescribing systems may decrease ambulatory prescribing errors, which are occurring at high rates among community-based providers.

Computerization of workflows, guidelines, and care pathways: a review of implementation challenges for process-oriented health information systems

OBJECTIVE

There is a need to integrate the various theoretical frameworks and formalisms for modeling clinical guidelines, workflows, and pathways, in order to move beyond providing support for individual clinical decisions and toward the provision of process-oriented, patient-centered, health information systems (HIS). In this review, we analyze the challenges in developing process-oriented HIS that formally model guidelines, workflows, and care pathways.

METHODS

A qualitative meta-synthesis was performed on studies published in English between 1995 and 2010 that addressed the modeling process and reported the exposition of a new methodology, model, system implementation, or system architecture. Thematic analysis, principal component analysis (PCA) and data visualisation techniques were used to identify and cluster the underlying implementation 'challenge' themes.

RESULTS

One hundred and eight relevant studies were selected for review. Twenty-five underlying 'challenge' themes were identified. These were clustered into 10 distinct groups, from which a conceptual model of the implementation process was developed.

DISCUSSION AND CONCLUSION

We found that the development of systems supporting individual clinical decisions is evolving toward the implementation of adaptable care pathways on the semantic web, incorporating formal, clinical, and organizational ontologies, and the use of workflow management systems. These architectures now need to be implemented and evaluated on a wider scale within clinical settings.

Development of a workflow integration survey (WIS) for implementing computerized clinical decision support

Interventions that focus on improving computerized clinical decision support (CDS) demonstrate that successful workflow integration can increase the adoption and use of CDS. However, metrics for assessing workflow integration in clinical settings are not well established. The goal of this study was to develop and validate a survey to assess the extent to which CDS is integrated into workflow. Qualitative data on CDS design, usability, and integration from four sites was collected by direct observation, interviews, and focus groups. Thematic analysis based on the sociotechnical systems theory revealed consistent themes across sites. Themes related to workflow integration included navigation, functionality, usability, and workload. Based on these themes, a brief 12-item scale to assess workflow integration was developed, refined, and validated with providers in a simulation study. To our knowledge, this is one of the first tools developed to specifically measure workflow integration of CDS.

Bedside electronic capture of clinical observations and automated clinical alerts to improve compliance with an Early Warning Score protocol

BACKGROUND

Failure to comply with clinical protocols and failure of communication to ensure delivery of the most appropriate timely clinical responses to patients whose conditions are acutely deteriorating have been shown to be significant causative factors associated with inhospital adverse events.

OBJECTIVE

To determine whether automated clinical alerts increase compliance with an Early Warning Score (EWS) protocol and improve patient outcomes.

METHODS

We performed a historically controlled study of bedside electronic capture of observations and automated clinical alerts. The primary outcome measure was hospital length of stay (LOS); secondary outcome measures were compliance with the EWS protocol, cardiac arrest incidence, critical care utilisation and hospital mortality.

RESULTS

Between baseline and intervention, 1481 consecutive patients were recruited generating 13 668 observation sets. There was a reduction in hospital LOS between the baseline and alert phase (9.7 days v 6.9 days, P < 0.001). EWS accuracy improved from 81% to 100% with electronic calculation. Clinical attendance to patients with EWS 3, 4 or 5 increased from 29% at baseline to 78% with automated alerts (P < 0.001). For patients with an EWS > 5, clinical attendance increased from 67% at baseline to 96% with automatic alerts (P < 0.001).

CONCLUSIONS

Electronic recording of patient observations linked to a computer system that calculates patient risk and then issues automatic graded alerts can improve clinical attendance to unstable general medical ward patients.

Opportunities and challenges in creating an international centralised knowledge base for clinical decision support systems in ePrescribing

Prescribing errors cause substantial potentially avoidable patient harm. There is increasing evidence that the implementation of clinical decision support systems to support prescribing may reduce the risk of such errors. Efforts have thus far concentrated on the implementation of these systems within local health communities. However, considerable potential benefit exists in sharing the content of these prescribing decision support systems across geographical boundaries, including the sharing of experiences and expertise and cost reduction, which could in turn potentially increase accessibility to low resource settings. Technical, commercial and regulatory issues would however first need to be overcome in order to facilitate such a development. In this paper, the authors reflect on some of the opportunities and challenges inherent in trying to develop an internationally agreed and shared computerised decision support system aiming to enhance prescribing safety.

Improving population care with an integrated electronic panel support tool

This study measured the impact of an electronic Panel Support Tool (PST) on primary care teams' performance on preventive, monitoring, and therapeutic evidence-based recommendations. The PST, tightly integrated with a comprehensive electronic health record, is a dynamic report that identifies gaps in 32 evidence-based care recommendations for individual patients, groups of patients selected by a provider, or all patients on a primary care provider's panel. It combines point-of-care recommendations, disease registry capabilities, and continuous performance feedback for providers. A serial cross-sectional study of the PST's impact on care performance was conducted, retrospectively using monthly summary data for 207 teams caring for 263,509 adult members in Kaiser Permanente's Northwest region. Baseline care performance was assessed 3 months before first PST use and at 4-month intervals over 20 months of follow-up. The main outcome measure was a monthly care performance percentage for each provider, calculated as the number of selected care recommendations that were completed for all patients divided by the number of clinical indications for care recommendations among them. Statistical analysis was performed using the t test and multiple regression. Average baseline care performance on the 13 measures was 72.9% (95% confidence interval [CI], 71.8%-74.0%). During the first 12 months of tool use, performance improved to a statistically significant degree every 4 months. After 20 months of follow-up, it increased to an average of 80.0% (95% CI, 79.3%-80.7%).

Medication related computerized decision support system (CDSS): make it a clinicians' partner!

Medication related Computerized Decision Support System (CDSS) are known to have a positive impact on Adverse Drug Events (ADE) prevention but they face acceptance problems due to over alerting and usability issues. We present here a Human factors approach to the design of these Clinical Decision Support (CDS) functions and to their integration into different Electronic Health Record (EHR) / Computerized Physicians Order Entry (CPOE) systems, so that the resulting CDSS corresponds to the users needs and fits clinical workflows and cognitive processes. We used ethnographic observations completed with semi-structured interviews to analyse existing work situations and work processes. These were then described in detail using the SHEL (Software, Hardware, Environment &amp; Liveware) formalism, which enables a structured description of the work system and provides an appropriate classification of human errors potentially leading to ADEs. We then propose a Unified Modelling Language (UML) model supporting the characterization by the CDSS of the drug monitoring and clinical context of patients at risk of ADE. This model combines the status of the lab test orders on the one hand with the validity and normality of the lab results on the other hand. This makes the system able to catch the context of the monitoring of the drugs through their corresponding lab tests and lab results (e.g. kalemia for potassium) and also part of the context of the clinical status of the patient (actual lab values, but also diseases and other pathologies that are identified as potential causes of the ADE e.g. renal insufficiency and potassium). We show that making the system able to catch the monitoring and clinical contexts opens interesting opportunities for the design of the CDS information content and display mode. Implementing this model would allow the CDSS to take into account the actions already engaged by the healthcare team and to adapt the information delivered to the monitoring and clinical context, thus making the CDSS a partner to the clinicians, nurses and pharmacists.