Improving respiratory vaccination rates in veterans with spinal cord injury/disorders: lessons learned

The burden of respiratory disease following a spinal cord injury/disorder (SCI/D) is well-described and experienced by patients, families, health care providers, and the health care delivery system. Despite the effectiveness of respiratory vaccinations (influenza and pneumococcal), vaccination rates in this population have been historically low. The Veterans Health Administration (VHA) Spinal Cord Injury Quality Enhancement Research Initiative (QUERI) developed a program to increase vaccination rates for veterans with SCI/D. Patient, provider, and system-level strategies were used. The purpose of the study was to improve vaccination rates in this population using multiple strategies. The result was significant improvement in vaccination rates following intervention. This paper describes the lessons learned in implementing best practices for vaccination. In addition, the basic elements of this program, and the similarities with the Chronic Care Model, are described.

Thinking beyond CPOE to integrated IT strategy and management

There is a tremendous amount of pressure driving organizations to implement computerized provider order entry. To unlock the greatest value, a more enterprise-wide strategic approach to healthcare IT is needed.

Continuous Quality Improvement for the Clinical Decision Unit

Clinical decision units (CDUs) are a relatively new and growing area of medicine in which patients undergo rapid evaluation and treatment. Continuous quality improvement (CQI) is important for the establishment and functioning of CDUs. CQI in CDUs has many advantages: better CDU functioning, fulfillment of Joint Commission on Accreditation of Healthcare Organizations mandates, greater efficiency/productivity, increased job satisfaction, better performance improvement, data availability, and benchmarking. Key elements include a database with volume indicators, operational policies, clinical practice protocols (diagnosis specific/condition specific), monitors, benchmarks, and clinical pathways. Examples of these important parameters are given. The CQI process should be individualized for each CDU and hospital.

Health care decision-support systems needed now

The technology exists now for developing a "Health Care Web" that would greatly improve health care decision making and research. But leaders must first be willing to cooperate to build the system.

Understanding hospital readiness for computerized physician order entry

BACKGROUND

Many hospitals in the United States are in early stages of decision making and planning to implement computerized physician order entry (CPOE) to improve patient safety and quality of care. The targeted processes and the software for CPOE are complex, and implementation is a large-scale change effort for most hospitals. Hospitals can increase the likelihood of success by understanding and addressing gaps in CPOE readiness. ASSESSING CPOE READINESS: A CPOE readiness assessment tool was developed that includes several different components: external environment; organizational leadership, structure, and culture; care standardization;, order management; access to information; information technology composition; and infrastructure. The presence or absence of these indicators in a particular hospital was determined by on-site interviews, walkarounds with direct observations, and document review.

RESULTS

Assessment results for the first 17 hospitals (bed size, 75-906 beds) indicated that the lowest average component score was in care standardization, while the highest average component score was in organizational structure and function. Organizational culture and the order management process also had low average scores.

CONCLUSIONS

This CPOE readiness assessment revealed significant gaps in all the hospitals examined. Identifying these gaps and addressing them before CPOE implementation can reduce risks. Organizations need to develop expertise at accomplishing and sustaining change; understanding and building CPOE readiness is an important first step.

[Impact of medical prescription computerisation on the incidence of adverse drug effects]

INTRODUCTION

Adverse drug effects are a significant public health problem. Prescription errors are responsible for a significant proportion of these adverse effects.

METHODS

We have aimed to improve the link between generation of and interpretation of a prescription through computerisation. The prescription sheet, which is generated daily, was organised to allow care planning without the need to re-copy out treatments on the sheet. A prescription aid was available which was based on a core group of drugs commonly used in our respiratory service. The aim of the study was to compare the various types of errors observed during 6 weeks of computerized prescriptions (229 files) to a retrospective series of handwritten prescriptions of the service at an identical time (184 files) the previous year. The case-mix was identical for both analysed periods.

RESULTS

The total number of technical prescribing errors in the 1,599 handwritten lines (49.27% error) was significantly higher (p<0.001) than the 1,805 computerized prescriptions lines (42.88% error). The errors of copying (p<0.001), eligibility (p<0.001) and incorrect spelling (p<0.05) were the main sources of error which were significantly reduced by computerisation.

CONCLUSION

Computerised prescription is likely to reduce the incidence of prescribing errors and adverse drug effects.

Decision support in medicine: lessons from the HELP system

PURPOSE

This report describes an ongoing transition from the HELP Hospital Information System to HELP II, a replacement Health Information System built to manage clinical information captured in a variety of medical settings. The focus of the article is on the medical decision support provided by this system and studied by researchers at the University of Utah and Intermountain Health Care (IHC), a large health care organization in Utah, for many years.

METHODS

Select success features of the original HELP system's decision support environment are identified and lessons learned are related. Plans for transferring these features to HELP II are discussed.

RESULTS

The article focuses on four features: (1) the importance of easy access to patient data essential for decision support, (2) the commitment to continued measurement and revision of both the logic and the interventional strategy in a decision support application, (3) experience with data mining as a tool for developing decision support tools, and (4) the role of clinical reports in supporting the decision making process.

Fusing a systematic and a case-based repository for medical decision support

In order to take full advantage of computer-based decision support in clinical practice, it makes sense to combine systems which support the same subject, but contribute to this task in different ways. At the Technical University of Munich, a Combined Clinical Decision Support System (C-CDSS) of this kind has been designed for gastroenterologists. The main goal of the system is to help the physicians in finding information which is relevant for making the right diagnoses or applying the proper therapy to his patients. To achieve this goal, not only systematic knowledge of the medical domain, but also case-based data is useful for a comparison of the actual case with well-documented similar cases of colleagues. The systematic knowledge comprises state-of-the-art textual information and selected multimedia contents in the sense of a standard textbook. The case-based information includes practice-related information on a pool of anonymized cases from clinical routine and also demonstrations of new techniques. By integrating these information resources into one service via a rule-based retrieval system, a powerful decision support system can be generated.

A framework for classifying decision support systems

BACKGROUND

Computer-based clinical decision support systems (CDSSs) vary greatly in design and function. A taxonomy for classifying CDSS structure and function would help efforts to describe and understand the variety of CDSSs in the literature, and to explore predictors of CDSS effectiveness and generalizability.

OBJECTIVE

To define and test a taxonomy for characterizing the contextual, technical, and workflow features of CDSSs.

METHODS

We retrieved and analyzed 150 English language articles published between 1975 and 2002 that described computer systems designed to assist physicians and/or patients with clinical decision making. We identified aspects of CDSS structure or function and iterated our taxonomy until additional article reviews did not result in any new descriptors or taxonomic modifications.

RESULTS

Our taxonomy comprises 95 descriptors along 24 descriptive axes. These axes are in 5 categories: Context, Knowledge and Data Source, Decision Support, Information Delivery, and Workflow. The axes had an average of 3.96 coded choices each. 75% of the descriptors had an inter-rater agreement kappa of greater than 0.6.

CONCLUSIONS

We have defined and tested a comprehensive, multi-faceted taxonomy of CDSSs that shows promising reliability for classifying CDSSs reported in the literature.

The use of computers for clinical care: a case series of advanced U.S. sites

OBJECTIVE

To describe advanced clinical information systems in the context in which they have been implemented and are being used.

DESIGN

Case series of five U.S. hospitals, including inpatient, ambulatory and emergency units. Descriptive study with data collected from interviews, observations, and document analysis.

MEASUREMENTS

The use of computerized results, notes, orders, and event monitors and the type of decision support; data capture mechanisms and data form; impact on clinician satisfaction and clinical processes and outcomes; and the organizational factors associated with successful implementation.

RESULTS

All sites have implemented a wide range of clinical information systems with extensive decision support. The systems had been well accepted by clinicians and have improved clinical processes. Successful implementation required leadership and long-term commitment, a focus on improving clinical processes, and gaining clinician involvement and maintaining productivity.

CONCLUSION

Despite differences in approach there are many similarities between sites in the clinical information systems in use and the factors important to successful implementation. The experience of these sites may provide a valuable guide for others who are yet to start, or are just beginning, the implementation of clinical information systems.

Distribution of a primary care office information system

Primary Care Office InSite (PCOI) is a Web-based intranet application that provides ready access to a collection of information useful in primary care. The PCOI Web site was developed by, and is widely used within, the Massachusetts General Hospital (MGH) and its affiliated community practices. Over 1600 users logged 60,000 separate sessions in the past year. The site contains clinical practice guidelines, patient educational material, drug prescription and cost information and referral information, all designed for use during routine patient care activity. This paper discusses the problems encountered and the lessons learned during an ongoing experiment to disseminate PCOI via the Internet to four distant and very different ambulatory care sites. None of these sites (a rural community hospital, a city-wide health care network, an inner-city general hospital, and an Indian Health Service hospital have the resources to develop such an application internally.

Community coronary units: strategies to promote pre-hospital thrombolysis

Early diagnosis and the early delivery of pre-hospital thrombolysis in cases of acute myocardial infarction (AMI) have been shown to decrease mortality. Despite strong evidence of its benefits, pre-hospital thrombolysis rates are still worryingly low. The challenge is to empower community practitioners to deliver thrombolysis. In the Grampian region there is a network of community hospitals which have been equipped with both videoconferencing and remote telemetry equipment. This allows realtime consultation with the local accident and emergency department and coronary care unit. Early trials of the system show that clinical information can be viewed in realtime, with transfer of a 12-lead electrocardiogram at 60 s intervals. This will give general practitioners unprecedented access to specialist advice. Our aim is to use a combination of teaching and decision support technology to ensure that all patients with AMI have the opportunity to access timely and appropriate prehospital thrombolysis.

Implementation of intelligent decision support systems in health care

The full implementation of any intelligent system in health care, which is designed for decision support, has several stages, from initial problem identification through development and, finally, cost-benefit analysis. Central to this is formal objectivist evaluation with its core component of inherent performance of the outputs from these systems. A Medline survey of one type of intelligent system is presented, which demonstrates that this issue is not being addressed adequately. Lack of criteria for dealing with the outputs from these "black box" systems to prescribe adequate levels of inherent performance may be preventing their being accepted by those in the health-care domain and, thus, their being applied widely in the field.

[Whether or not to treat pneumonia curatively in (demented) psychogeriatric patients: evaluation of a guideline for nursing home physicians]

A guideline was developed to support decision-making about whether or not to treat pneumonia curatively in psychogeriatric (demented) nursing home patients. This guideline was developed as a 'checklist of considerations', primarily of the ethical and legal aspects of decision-making. Nursing home physicians used and evaluated the list. The list's acceptance was assessed by measuring the frequency of the list's use, and judgements of the list's contents and 'usefulness'. The list was used in 50 out of 58 participating nursing homes, in 47% of the 489 psychogeriatric patients in whom pneumonia occurred. The list was found somewhat to very useful to support decision-making in 47% of 107 individual patients. For the targeted patient category as a whole, 85% of 48 physicians who were asked retrospectively (one physician per home) found the list somewhat to very useful. The content of the list was judged favourably. In conclusion, the nursing home physicians accepted the considerations of the checklist as a basis for decision-making on whether or not to treat pneumonia curatively in psychogeriatric patients. In the future, the format of the list can be adapted for use in diverse clinical situations. Suggestions are provided to increase user friendliness and usefulness.

Info tech's next step. What's driving the race to market this new generation of clinical systems?

A new generation of clinical IT systems has hit the market all at once. Is this vigorous competition vendor driven, or has health care--and the technology needed to support it--fundamentally changed? And what does it all mean for hospitals struggling to decide where to spend the big bucks it takes to remain technologically viable?

Implementing clinical information systems: a multiple-case study within a US hospital

The rapid movement of information technologies into health care organizations has raised managerial concern regarding the capability of today's institutions to satisfactorily manage their introduction. Indeed, several health care institutions have consumed huge amounts of money and frustrated countless people in wasted information systems implementation efforts. Unfortunately, there are no easy answers as to why so many health informatics projects are not more successful. The aim of this study is to provide a deeper understanding of clinical information systems implementation. The research reported in this paper focuses on building a theory of the dynamic nature of the implementation process, that is, the how and why of what happened. The general approach taken was inspired by the work of Eisenhardt (1989) on building theories from case study research. We examined the implementation process, use and consequences of three distinct clinical information systems at a large tertiary care teaching hospital. A series of four research propositions reflecting the dynamic nature of the implementation process are offered as each of the three cases are analyzed. Findings add a number of new perspectives and empirical insights to the existing body of knowledge in the fields of IT implementation and medical informatics.

A comparative case study of two models of a clinical informaticist service

OBJECTIVES

To describe and evaluate two different models of a clinical informaticist service.

DESIGN

A case study approach, using various qualitative methods to illuminate the complexity of the project groups' experiences.

SETTING

UK primary health care.

INTERVENTIONS

Two informaticist projects to provide evidence based answers to questions arising in clinical practice and thereby support high quality clinical decision making by practitioners.

RESULTS

The projects took contrasting and complementary approaches to establishing the service. One was based in an academic department of primary health care. The service was academically highly rigorous, remained true to its original proposal, included a prominent research component, and involved relatively little personal contact with practitioners. This group achieved the aim of providing general information and detailed guidance to others intending to set up a similar service. The other group was based in a service general practice and took a much more pragmatic, flexible, and facilitative approach. They achieved the aim of a credible, acceptable, and sustainable service that engaged local practitioners beyond the innovators and enthusiasts and secured continued funding.

CONCLUSION

An informaticist service should be judged on at least two aspects of quality---an academic dimension (the technical quality of the evidence based answers) and a service dimension (the facilitation of questioning behaviour and implementation). This study suggests that, while the former may be best achieved within an academic environment, the latter requires a developmental approach in which pragmatic service considerations are addressed.

Clinical decision support systems: a discussion of quality, safety and legal liability issues

Developers of Clinical Decision Support Systems (CDSSs) have to date been more concerned with the efficacy of systems (e.g. measurable improvements in clinical outcomes) than with safety (e.g. potential for harmful side-effects). In future CDSS developers will be required (by the courts etc.) to acknowledge a "duty of care" covering all aspects of design, development and deployment. Experience in the transport, power and other safety-critical industries has led to a range of quality and safety assurance methods whose adoption may be needed before CDSSs can safely become an integral part of routine patient care, and before the trust of healthcare professionals, patients and other stakeholders can be gained. No single method will be sufficient for safe development and deployment; a range of techniques will be needed and used selectively. This paper is a contribution to discussion of quality, safety and legal liability issues in the medical informatics community.

A clinical rules taxonomy for the implementation of a computerized physician order entry (CPOE) system

Many of the benefits of computerized physician order entry (CPOE) stem from its ability to support medical decision-making and error-reduction during patient care. This automated "intelligence" is typically represented by a network of rules. We describe a taxonomic representation of clinical decision-support rules in the context of developing and implementing a de novo CPOE and decision-support system. In our experience, this clinical rules taxonomy facilitated our implementation goals in the areas of physician acceptance and approval, rules construction and maintenance, and technical development and testing. This rules taxonomy may eventually be used to establish standards by which CPOE-based decision-support is measured.

Development and impact of a computerized pediatric antiinfective decision support program

OBJECTIVE

Computerized medical decision support tools have been shown to improve the quality of care and have been cited by the Institute of Medicine as one method to reduce pharmaceutical errors. We evaluated the impact of an antiinfective decision support tool in a pediatric intensive care unit (PICU).

METHODS

We enhanced an existing adult antiinfective management tool by adding and changing medical logic to make it appropriate for pediatric patients. Process and outcomes measures were monitored prospectively during a 6-month control and a 6-month intervention period. Mandatory use of the decision support tool was initiated for all antiinfective orders in a 26-bed PICU during the intervention period. Clinician opinions of the decision support tool were surveyed via questionnaire.

RESULTS

The rate of pharmacy interventions for erroneous drug doses declined by 59%. The rate of anti-infective subtherapeutic patient days decreased by 36%, and the rate of excessive-dose days declined by 28%. The number of orders placed per antiinfective course decreased 11.5%, and the robust estimate of the antiinfective costs per patient decreased 9%. The type of anti-infectives ordered and the number of antiinfective doses per patient remained similar, as did the rates of adverse drug events and antibiotic-bacterial susceptibility mismatches. The surveyed clinicians reported that use of the program improved their antiinfective agent choices as well as their awareness of impairments in renal function and reduced the likelihood of adverse drug events.

CONCLUSIONS

Use of the pediatric antiinfective decision support tool in a PICU was considered beneficial to patient care by the clinicians and reduced the rates of erroneous drug orders, improved therapeutic dosage targets, and was associated with a decreased robust estimate of antiinfective costs per patient. antiinfective agents, decision support systems, drug therapy, medication errors, child, infant.