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Born C, Schwarz R, Böttcher TP, Hein A, Krcmar H. The role of information systems in emergency department decision-making-a literature review. J Am Med Inform Assoc 2024; 31:1608-1621. [PMID: 38781289 PMCID: PMC11187435 DOI: 10.1093/jamia/ocae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED. MATERIALS AND METHODS We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes. RESULTS Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes. DISCUSSION Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation. CONCLUSION We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.
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Affiliation(s)
- Cornelius Born
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Romy Schwarz
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Timo Phillip Böttcher
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Andreas Hein
- Institute of Information Systems and Digital Business, University of St. Gallen, 9000 St. Gallen, Switzerland
| | - Helmut Krcmar
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
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Amici LD, van Pelt M, Mylott L, Langlieb M, Nanji KC. Clinical Decision Support as a Prevention Tool for Medication Errors in the Operating Room: A Retrospective Cross-Sectional Study. Anesth Analg 2024:00000539-990000000-00828. [PMID: 38870073 DOI: 10.1213/ane.0000000000007058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Medication errors in the operating room have high potential for patient harm. While electronic clinical decision support (CDS) software has been effective in preventing medication errors in many nonoperating room patient care areas, it is not yet widely used in operating rooms. The purpose of this study was to determine the percentage of self-reported intraoperative medication errors that could be prevented by CDS algorithms. METHODS In this retrospective cross-sectional study, we obtained safety reports involving medication errors documented by anesthesia clinicians between August 2020 and August 2022 at a 1046-bed tertiary care academic medical center. Reviewers classified each medication error by its stage in the medication use process, error type, presence of an adverse medication event, and its associated severity and preventability by CDS. Informational gaps were corroborated by retrospective chart review and disagreements between reviewers were resolved by consensus. The primary outcome was the percentage of errors that were preventable by CDS. Secondary outcomes were preventability by CDS stratified by medication error type and severity. RESULTS We received 127 safety reports involving 80 medication errors, and 76/80 (95%) of the errors were classified as preventable by CDS. Certain error types were more likely to be preventable by CDS than others (P < .001). The most likely error types to be preventable by CDS were wrong medication (N = 36, 100% rated as preventable), wrong dose (N = 30, 100% rated as preventable), and documentation errors (N = 3, 100% rated as preventable). The least likely error type to be preventable by CDS was inadvertent bolus (N = 3, none rated as preventable). CONCLUSIONS Ninety-five percent of self-reported medication errors in the operating room were classified as preventable by CDS. Future research should include a randomized controlled trial to assess medication error rates and types with and without the use of CDS.
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Affiliation(s)
- Lynda D Amici
- From the Northeastern University School of Nursing, Boston, Massachusetts
| | - Maria van Pelt
- From the Northeastern University School of Nursing, Boston, Massachusetts
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Laura Mylott
- From the Northeastern University School of Nursing, Boston, Massachusetts
| | - Marin Langlieb
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen C Nanji
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
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Rahimi F, Rabiei R, Seddighi AS, Roshanpoor A, Seddighi A, Moghaddasi H. Features and functions of decision support systems for appropriate diagnostic imaging: a scoping review. Diagnosis (Berl) 2024; 11:4-16. [PMID: 37795534 DOI: 10.1515/dx-2023-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/10/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Diagnostic imaging decision support (DI-DS) systems could be effective tools for reducing inappropriate diagnostic imaging examinations. Since effective design and evaluation of these systems requires in-depth understanding of their features and functions, the present study aims to map the existing literature on DI-DS systems to identify features and functions of these systems. METHODS The search was performed using Scopus, Embase, PubMed, Web of Science, and Cochrane Central Registry of Controlled Trials (CENTRAL) and was limited to 2000 to 2021. Analytical studies, descriptive studies, reviews and book chapters that explicitly addressed the functions or features of DI-DS systems were included. RESULTS A total of 6,046 studies were identified. Out of these, 55 studies met the inclusion criteria. From these, 22 functions and 22 features were identified. Some of the identified features were: visibility, content chunking/grouping, deployed as a multidisciplinary program, clinically valid and relevant feedback, embedding current evidence, and targeted recommendations. And, some of the identified functions were: displaying an appropriateness score, recommending alternative or more appropriate imaging examination(s), providing recommendations for next diagnostic steps, and providing safety alerts. CONCLUSIONS The set of features and functions obtained in the present study can provide a basis for developing well-designed DI-DS systems, which could help to improve adherence to diagnostic imaging guidelines, minimize unnecessary costs, and improve the outcome of care through appropriate diagnosis and on-time care delivery.
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Affiliation(s)
- Fatemeh Rahimi
- Department of Health Information Technology and Management, Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Rabiei
- Department of Health Information Technology and Management, Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Saied Seddighi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Roshanpoor
- Department of computer, Yadegar-e-Imam Khomeini (RAH), Janat-abad Branch, Islamic Azad University, Tehran, Iran
| | - Afsoun Seddighi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Moghaddasi
- Department of Health Information Technology and Management, Health Information Management & Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Darband St., Tehran, Iran
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Bhaumik D, Bhaumik SS, Thaker AA, Timpone VM, Bills CB, Patten L, Pattee J, Chow D, Sugrue LP, Callen AL. Ordering Characteristics Predictive of Noncontrast CT Head Positivity in the Emergency Department. Acad Radiol 2023; 30:492-498. [PMID: 35654657 DOI: 10.1016/j.acra.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 01/25/2023]
Abstract
RATIONALE AND OBJECTIVES Recent decades have seen a steady increase in noncontrast head CT utilization in the emergency department with a concurrent rise in the practice of physician assistants (PAs) and nurse practitioners (NPs). The goal of this study was to identify ordering and patient characteristics predictive of positive noncontrast head CTs in the ED. We hypothesized NP/PAs would have lower positivity rates compared to physicians, suggestive of relative overutilization. MATERIALS AND METHODS We retrospectively identified ED patients who underwent noncontrast head CTs at a single institution: a nonlevel 1 trauma center, during a 7-year period, recording examination positivity, ordering provider training/experience, and multiple additional ordering/patient attributes. Exam positivity was defined as any intracranial abnormality necessitating a change in acute management, such as acute hemorrhage, hydrocephalus, herniation, or worsening prior findings. RESULTS 6624 patients met inclusion criteria. 4.6% (280/6107) of physician exams were positive while 3.7% (19/517) of NP/PA exams were positive; however, differences were not significant. Increasing provider experience was not associated with positivity. Attributes with increased positivity were patient age (p < 0.001), daytime exam (p < 0.05), and indications regarding malignancy (p < 0.001) or focal neurologic deficit (p = 0.001). Attributes with decreased positivity were indications of trauma (p < 0.001) or vertigo/dizziness (p < 0.05). CONCLUSION We found no significant difference in rates of exam positivity between physicians and NP/PAs, even accounting for years of experience. This suggests increasing utilization of head CTs in the ED is not due to the increasing presence of NP/PAs, and may be reflective of general practice trends and clear diagnostic algorithms leading to head CT.
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Affiliation(s)
- Debayan Bhaumik
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA
| | - Smitha S Bhaumik
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ashesh A Thaker
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA
| | - Vincent M Timpone
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA
| | - Corey B Bills
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Luke Patten
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jack Pattee
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel Chow
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Leo P Sugrue
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Andrew L Callen
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA.
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Peters S, Sukumar K, Blanchard S, Ramasamy A, Malinowski J, Ginex P, Senerth E, Corremans M, Munn Z, Kredo T, Remon LP, Ngeh E, Kalman L, Alhabib S, Amer YS, Gagliardi A. Trends in guideline implementation: an updated scoping review. Implement Sci 2022; 17:50. [PMID: 35870974 PMCID: PMC9308215 DOI: 10.1186/s13012-022-01223-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022] Open
Abstract
Background Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review. Methods We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics. Results We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions. Conclusions Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact. Trial registration The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01223-6.
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Lacson R, Eskian M, Cochon L, Gujrathi I, Licaros A, Zhao A, Vetrano N, Schneider L, Raja A, Khorasani R. Representing narrative evidence as clinical evidence logic statements. JAMIA Open 2022; 5:ooac024. [PMID: 35474718 PMCID: PMC9030217 DOI: 10.1093/jamiaopen/ooac024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 03/05/2022] [Accepted: 03/25/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objective
Clinical evidence logic statements (CELS) are shareable knowledge artifacts in a semistructured “If-Then” format that can be used for clinical decision support systems. This project aimed to assess factors facilitating CELS representation.
Materials and Methods
We described CELS representation of clinical evidence. We assessed factors that facilitate representation, including authoring instruction, evidence structure, and educational level of CELS authors. Five researchers were tasked with representing CELS from published evidence. Represented CELS were compared with the formal representation. After an authoring instruction intervention, the same researchers were asked to represent the same CELS and accuracy was compared with that preintervention using McNemar’s test. Moreover, CELS representation accuracy was compared between evidence that is structured versus semistructured, and between CELS authored by specialty-trained versus nonspecialty-trained researchers, using χ2 analysis.
Results
261 CELS were represented from 10 different pieces of published evidence by the researchers pre- and postintervention. CELS representation accuracy significantly increased post-intervention, from 20/261 (8%) to 63/261 (24%, P value < .00001). More CELS were assigned for representation with 379 total CELS subsequently included in the analysis (278 structured and 101 semistructured) postintervention. Representing CELS from structured evidence was associated with significantly higher CELS representation accuracy (P = .002), as well as CELS representation by specialty-trained authors (P = .0004).
Discussion
CELS represented from structured evidence had a higher representation accuracy compared with semistructured evidence. Similarly, specialty-trained authors had higher accuracy when representing structured evidence.
Conclusion
Authoring instructions significantly improved CELS representation with a 3-fold increase in accuracy. However, CELS representation remains a challenging task.
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Affiliation(s)
- Ronilda Lacson
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mahsa Eskian
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Laila Cochon
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Isha Gujrathi
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Andro Licaros
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Anna Zhao
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Vetrano
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Louise Schneider
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Raja
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ramin Khorasani
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Papa L, Ladde JG, O’Brien JF, Thundiyil JG, Tesar J, Leech S, Cassidy DD, Roa J, Hunter C, Miller S, Baker S, Parrish GA, Davison J, Van Dillen C, Ralls GA, Briscoe J, Falk JL, Weber K, Giordano PA. Evaluation of Glial and Neuronal Blood Biomarkers Compared With Clinical Decision Rules in Assessing the Need for Computed Tomography in Patients With Mild Traumatic Brain Injury. JAMA Netw Open 2022; 5:e221302. [PMID: 35285924 PMCID: PMC9907341 DOI: 10.1001/jamanetworkopen.2022.1302] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE In 2018, the combination of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) levels became the first US Food and Drug Administration-approved blood test to detect intracranial lesions after mild to moderate traumatic brain injury (MTBI). How this blood test compares with validated clinical decision rules remains unknown. OBJECTIVES To compare the performance of GFAP and UCH-L1 levels vs 3 validated clinical decision rules for detecting traumatic intracranial lesions on computed tomography (CT) in patients with MTBI and to evaluate combining biomarkers with clinical decision rules. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study from a level I trauma center enrolled adults with suspected MTBI presenting within 4 hours of injury. The clinical decision rules included the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), and National Emergency X-Radiography Utilization Study II (NEXUS II) criteria. Emergency physicians prospectively completed data forms for each clinical decision rule before the patients' CT scans. Blood samples for measuring GFAP and UCH-L1 levels were drawn, but laboratory personnel were blinded to clinical results. Of 2274 potential patients screened, 697 met eligibility criteria, 320 declined to participate, and 377 were enrolled. Data were collected from March 16, 2010, to March 5, 2014, and analyzed on August 11, 2021. MAIN OUTCOMES AND MEASURES The presence of acute traumatic intracranial lesions on head CT scan (positive CT finding). RESULTS Among enrolled patients, 349 (93%) had a CT scan performed and were included in the analysis. The mean (SD) age was 40 (16) years; 230 patients (66%) were men, 314 (90%) had a Glasgow Coma Scale score of 15, and 23 (7%) had positive CT findings. For the CCHR, sensitivity was 100% (95% CI, 82%-100%), specificity was 33% (95% CI, 28%-39%), and negative predictive value (NPV) was 100% (95% CI, 96%-100%). For the NOC, sensitivity was 100% (95% CI, 82%-100%), specificity was 16% (95% CI, 12%-20%), and NPV was 100% (95% CI, 91%-100%). For NEXUS II, sensitivity was 83% (95% CI, 60%-94%), specificity was 52% (95% CI, 47%-58%), and NPV was 98% (95% CI, 94%-99%). For GFAP and UCH-L1 levels combined with cutoffs at 67 and 189 pg/mL, respectively, sensitivity was 100% (95% CI, 82%-100%), specificity was 25% (95% CI, 20%-30%), and NPV was 100%; with cutoffs at 30 and 327 pg/mL, respectively, sensitivity was 91% (95% CI, 70%-98%), specificity was 20% (95% CI, 16%-24%), and NPV was 97%. The area under the receiver operating characteristic curve (AUROC) for GFAP alone was 0.83; for GFAP plus NEXUS II, 0.83; for GFAP plus NOC, 0.85; and for GFAP plus CCHR, 0.88. The AUROC for UCH-L1 alone was 0.72; for UCH-L1 plus NEXUS II, 0.77; for UCH-L1 plus NOC, 0.77; and for UCH-L1 plus CCHR, 0.79. The GFAP biomarker alone (without UCH-L1) contributed the most improvement to the clinical decision rules. CONCLUSIONS AND RELEVANCE In this cohort study, the CCHR, the NOC, and GFAP plus UCH-L1 biomarkers had equally high sensitivities, and the CCHR had the highest specificity. However, using different cutoff values reduced both sensitivity and specificity of GFAP plus UCH-L1. Use of GFAP significantly improved the performance of the clinical decision rules, independently of UCH-L1. Together, the CCHR and GFAP had the highest diagnostic performance.
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Affiliation(s)
- Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Jay G. Ladde
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - John F. O’Brien
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Josef G. Thundiyil
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - James Tesar
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - David D. Cassidy
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Jesus Roa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Christopher Hunter
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Susan Miller
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Sara Baker
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Gary A. Parrish
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Christine Van Dillen
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - George A. Ralls
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Joshua Briscoe
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Jay L. Falk
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Kurt Weber
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Philip A. Giordano
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
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Zare S, Mobarak Z, Meidani Z, Nabovati E, Nazemi Z. Effectiveness of Clinical Decision Support Systems on the Appropriate Use of Imaging for Central Nervous System Injuries: A Systematic Review. Appl Clin Inform 2022; 13:37-52. [PMID: 35021254 PMCID: PMC8754686 DOI: 10.1055/s-0041-1740921] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/08/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND One of the best practices for timely and efficient diagnoses of central nervous system (CNS) trauma and complex diseases is imaging. However, rates of imaging for CNS are high and impose a lot of costs to health care facilities in addition to exposing patients with negative impact of ionizing radiation. OBJECTIVES This study aimed to systematically review the effects and features of clinical decision support systems (CDSSs) for the appropriate use of imaging for CNS injuries. METHOD We searched MEDLINE, SCOPUS, Web of Science, and Cochrane without time period restriction. We included experimental and quasiexperimental studies that assessed the effectiveness of CDSSs designed for the appropriate use of imaging for CNS injuries in any clinical setting, including primary, emergency, and specialist care. The outcomes were categorized based on imaging-related, physician-related, and patient-related groups. RESULT A total of 3,223 records were identified through the online literature search. Of the 55 potential papers for the full-text review, 11 eligible studies were included. Reduction of CNS imaging proportion varied from 2.6 to 40% among the included studies. Physician-related outcomes, including guideline adherence, diagnostic yield, and knowledge, were reported in five studies, and all demonstrated positive impact of CDSSs. Four studies had addressed patient-related outcomes, including missed or delayed diagnosis, as well as length of stay. These studies reported a very low rate of missed diagnosis due to the cancellation of computed tomography (CT) examine according to the CDSS recommendations. CONCLUSION This systematic review reports that CDSSs decrease the utilization of CNS CT scan, while increasing physicians' adherence to the rules. However, the possible harm of CDSSs to patients was not well addressed by the included studies and needs additional investigation. The actual effect of CDSSs on appropriate imaging would be realized when the saved cost of examinations is compared with the cost of missed diagnosis.
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Affiliation(s)
- Sahar Zare
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Zohre Mobarak
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Zahra Meidani
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Ehsan Nabovati
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Zahra Nazemi
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
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Engineer RS, Podolsky SR, Fertel BS, Grover P, Jimenez H, Simon EL, Smalley CM. A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department Using a Clinical Decision Support Tool and a Structured Parent Discussion Tool. Pediatr Emerg Care 2021; 37:e1670-e1674. [PMID: 29768294 DOI: 10.1097/pec.0000000000001501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool. METHODS A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013. RESULTS The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group. CONCLUSION A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.
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Affiliation(s)
- Rakesh S Engineer
- From the Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH
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Rousseau JF, Ip IK, Raja AS, Schuur JD, Khorasani R. Can emergency department provider notes help to achieve more dynamic clinical decision support? J Am Coll Emerg Physicians Open 2020; 1:1269-1277. [PMID: 33392531 PMCID: PMC7771753 DOI: 10.1002/emp2.12232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/31/2020] [Accepted: 08/05/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Assess whether clinical data were present in emergency department (ED) provider notes at time of order entry for cervical spine (c-spine) imaging that could be used to augment or pre-populate clinical decision support (CDS) attributes. METHODS This Institutional Review Board-approved retrospective study, performed in a quaternary hospital, included all encounters for adult ED patients seen April 1, 2013-September 30, 2014 for a chief complaint of trauma who received c-spine computed tomography (CT) or x-ray. We assessed proportion of ED encounters with at least 1 c-spine-specific CDS rule attribute in clinical notes available at the time of imaging order and agreement between attributes in clinical notes and data entered into CDS. RESULTS A portion of the clinical note was submitted before imaging order in 42% (184/438) of encounters reviewed; 59.2% (109/184) of encounters with note portions submitted before imaging order had at least 1 positive CDS attribute identified supporting imaging study appropriateness; 34.8% (64/184) identified exclusion criteria where CDS appropriateness recommendations would not be applicable. 65.8% (121/184) of encounters had either a positive CDS attribute or an exclusion criterion. Concordance of c-spine CDS attributes when present in both notes and CDS was 68.4% (κ = 0.35 95% CI: 0.15-0.56; McNemar P = 0.23). CONCLUSIONS Clinical notes are an underutilized source of clinical attributes needed for CDS, available in a substantial percentage of encounters at the time of imaging order. Automated pre-population of imaging order requisitions with relevant clinical information extracted from electronic health record provider notes may: (1) improve ordering efficiency by reducing redundant data entry, (2) help improve clinical relevance of CDS alerts, and (3) potentially reduce provider burnout from extraneous alerts.
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Affiliation(s)
- Justin F. Rousseau
- Center for Evidence‐Based ImagingBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of Population HealthDell Medical School, The University of Texas at AustinAustinTexasUSA
- Department of NeurologyDell Medical School, The University of Texas at AustinAustinTexasUSA
| | - Ivan K. Ip
- Center for Evidence‐Based ImagingBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Ali S. Raja
- Center for Evidence‐Based ImagingBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Jeremiah D. Schuur
- Department of Emergency MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Ramin Khorasani
- Center for Evidence‐Based ImagingBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
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11
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Abstract
Healthcare today provides an especially rich context for the intertwined transformation of work and the technologies of work, which need to be understood in tandem. Advances in artificial intelligence, robotics, the internet of things, and computational science promise to transform healthcare. The slow speed of organizational and professional change compared to the rapid innovation of healthcare technology makes it a compelling context for engaged scholarship. Sorting through the promise, hype, and reality of the datafication and automation of health and healthcare presents challenges that communication scholarship can help address. In this essay, I share my own healthcare paperwork and information technology story and discuss implications for the study of health information technology, automation, and healthcare work.
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Affiliation(s)
- Joshua B Barbour
- Department of Communication Studies, The University of Texas at Austin
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12
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Ciprut SE, Kelly MD, Walter D, Hoffman R, Becker DJ, Loeb S, Sedlander E, Tenner CT, Sherman SE, Zeliadt SB, Makarov DV. A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study. Urology 2020; 145:113-119. [PMID: 32721517 DOI: 10.1016/j.urology.2020.05.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/19/2020] [Accepted: 05/11/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. METHODS We implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. RESULTS FIFTY SEVEN PERCENT: (117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care. CONCLUSION While the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.
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Affiliation(s)
- Shannon E Ciprut
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY
| | - Matthew D Kelly
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY.
| | - Dawn Walter
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY
| | | | - Daniel J Becker
- VA New York Harbor Healthcare System, New York, NY; Department of Oncology, New York University, New York, NY; Perlmutter Cancer Center, New York University, New York, NY
| | - Stacy Loeb
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY
| | - Erica Sedlander
- Department of Prevention and Community Health, George Washington University, Milken Institute School of Public Health, Washington, DC
| | - Craig T Tenner
- VA New York Harbor Healthcare System, New York, NY; Department of Medicine - General Internal Medicine, New York University, New York, NY
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York, NY; Department of Population Health, New York University, New York, NY
| | - Steven B Zeliadt
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, Washington; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Danil V Makarov
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY; Perlmutter Cancer Center, New York University, New York, NY; Robert F. Wagner Graduate School of Public Service, New York University, New York, NY
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13
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Agarwal M, Udare A, Patlas M, Ramonas M, Alaref AA, Rozenberg R, Ly DL, Golev DS, Mascola K, van der Pol CB. Effect of COVID-19 on computed tomography usage and critical test results in the emergency department: an observational study. CMAJ Open 2020; 8:E568-E576. [PMID: 32928878 PMCID: PMC7505522 DOI: 10.9778/cmajo.20200148] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The effect of the coronavirus disease 2019 (COVID-19) pandemic on new or unexpected radiologic findings in the emergency department (ED) is unclear. The aim of this study was to determine the effect of the COVID-19 pandemic on the number of computed tomography (CT) critical test results in the ED. METHODS We performed a retrospective observational study of ED CT usage at 4 Ontario hospitals (1 urban academic, 1 northern academic, 1 urban community and 1 rural community) over 1 month during the COVID-19 pandemic (April 2020) and over the same month 1 year earlier (April 2019; before the pandemic). The CT findings from 1 of the 4 hospitals, Hamilton Health Sciences, were reviewed to determine the number of critical test results by body region. Total CT numbers were compared using Poisson regression and CT yields were compared using the χ2 test. RESULTS The median number of ED CT examinations per day was markedly lower during the COVID-19 pandemic than before the pandemic (82 v. 133, p < 0.01), with variation across hospitals (p = 0.001). On review of 1717 CT reports from Hamilton Health Sciences, fewer critical test results were demonstrated on CT pulmonary angiograms (43 v. 88, p < 0.001) and CT examinations of the head (82 v. 112, p < 0.03) during the pandemic than before the pandemic; however, the yield of these examinations did not change. Although the absolute number of all CT examinations with critical test results decreased, the number of CT examinations without critical results decreased more, resulting in a higher yield of CT for critical test results during the pandemic (46% [322/696] v. 37% [379/1021], p < 0.01). INTERPRETATION Emergency department CT volumes markedly decreased during the COVID-19 pandemic, predominantly because there were fewer examinations with new or unexpected findings. This suggests that COVID-19 public information campaigns influenced the behaviours of patients presenting to the ED.
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Affiliation(s)
- Minu Agarwal
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont
| | - Amar Udare
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont
| | - Michael Patlas
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont
| | - Milita Ramonas
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont
| | - Amer A Alaref
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont
| | - Radu Rozenberg
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont
| | - Donald L Ly
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont
| | - Dmitry S Golev
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont
| | - Ken Mascola
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont
| | - Christian B van der Pol
- Departm=ent of Radiology (Agarwal, Udare, Patlas, Ramonas, Mascola, van der Pol), Hamilton Health Sciences; Department of Radiology (Agarwal, Udare, Patlas, Ramonas, van der Pol), McMaster University, Hamilton, Ont.; Thunder Bay Regional Health Sciences Centre (Alaref, Rozenberg); Northern Ontario School of Medicine (Alaref, Rozenberg), Thunder Bay, Ont.; Mackenzie Health (Ly), Richmond Hill, Ont.; Orillia Soldiers' Memorial Hospital (Golev), Orillia, Ont.
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14
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Intent of health care providers to adopt a clinical decision support tool in the management of minor pediatric head injuries. J Am Assoc Nurse Pract 2019; 32:168-175. [PMID: 30951010 DOI: 10.1097/jxx.0000000000000208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Radiographic neuroimaging in minor pediatric head injuries contains risks of radiation-induced malignancy. The Pediatric Emergency Care Applied Research Network (PECARN) head injury protocol identifies head-injured children who are at very low risk of clinically important traumatic brain injuries and can safely not receive a head computed tomography (CT) scan. LOCAL PROBLEM The identified urgent care facility had no facility-wide protocol to manage head injuries. METHODS The purpose of the evidence-based practice project was to educate health care providers on the risks of indiscriminate head CT prescription and the utility of the PECARN head injury protocol in the management of minor pediatric head injuries. INTERVENTIONS A knowledge assessment was conducted using pre- and posttests and the likelihood to adopt the PECARN head injury protocol in clinical practice was evaluated using the Evidence-Based Practice Attitude Scale. Additionally, rates of head CT scans ordered that were inappropriate according to the PECARN head injury protocol were calculated postproject and compared with preproject rates. RESULTS Data analysis was performed using descriptive statistics. Findings included increase in provider knowledge on the use of the PECARN head injury protocol and high likelihood of intent to adopt the PECARN head injury protocol in clinical practice. In addition, rates of head CT prescription postproject were lower than preproject rates, and 82.61% of CT scans ordered postproject were appropriate according to the PECARN head injury protocol. CONCLUSIONS Using the PECARN head injury protocol was associated with consistency of care, reduced unnecessary health care resource utilization, and health care costs.
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15
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Rousseau JF, Ip IK, Raja AS, Valtchinov VI, Cochon L, Schuur JD, Khorasani R. Can Automated Retrieval of Data from Emergency Department Physician Notes Enhance the Imaging Order Entry Process? Appl Clin Inform 2019; 10:189-198. [PMID: 30895573 PMCID: PMC6426724 DOI: 10.1055/s-0039-1679927] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND When a paucity of clinical information is communicated from ordering physicians to radiologists at the time of radiology order entry, suboptimal imaging interpretations and patient care may result. OBJECTIVES Compare documentation of relevant clinical information in electronic health record (EHR) provider note to computed tomography (CT) order requisition, prior to ordering of head CT for emergency department (ED) patients presenting with headache. METHODS In this institutional review board-approved retrospective observational study performed between April 1, 2013 and September 30, 2014 at an adult quaternary academic hospital, we reviewed data from 666 consecutive ED encounters for patients with headaches who received head CT. The primary outcome was the number of concept unique identifiers (CUIs) relating to headache extracted via ontology-based natural language processing from the history of present illness (HPI) section in ED notes compared with the number of concepts obtained from the imaging order requisition. RESULTS Our analysis was conducted on cases where the HPI note section was completed prior to image order entry, which occurred in 23.1% (154/666) of encounters. For these 154 encounters, the number of CUIs specific to headache per note extracted from the HPI (median = 3, interquartile range [IQR]: 2-4) was significantly greater than the number of CUIs per encounter obtained from the imaging order requisition (median = 1, IQR: 1-2; Wilcoxon signed rank p < 0.0001). Extracted concepts from notes were distinct from order requisition indications in 92.9% (143/154) of cases. CONCLUSION EHR provider notes are a valuable source of relevant clinical information at the time of imaging test ordering. Automated extraction of clinical information from notes to prepopulate imaging order requisitions may improve communication between ordering physicians and radiologists, enhance efficiency of ordering process by reducing redundant data entry, and may help improve clinical relevance of clinical decision support at the time of order entry, potentially reducing provider burnout from extraneous alerts.
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Affiliation(s)
- Justin F Rousseau
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Population Health, Dell Medical School, Austin, Texas, United States.,Department of Neurology, Dell Medical School, Austin, Texas, United States
| | - Ivan K Ip
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Ali S Raja
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Vladimir I Valtchinov
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States
| | - Laila Cochon
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Ramin Khorasani
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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16
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Effect of Clinical Decision Support on Appropriateness of Advanced Imaging Use Among Physicians-in-Training. AJR Am J Roentgenol 2019; 212:859-866. [PMID: 30779671 DOI: 10.2214/ajr.18.19931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Clinical decision support (CDS) tools have been shown to reduce inappropriate imaging orders. We hypothesized that CDS may be especially effective for house staff physicians who are prone to overuse of resources. MATERIALS AND METHODS Our hospital implemented CDS for CT and MRI orders in the emergency department with scores based on the American College of Radiology's Appropriateness Criteria (range, 1-9; higher scores represent more-appropriate orders). Data on CT and MRI orders from April 2013 through June 2016 were categorized as pre-CDS or baseline, post-CDS period 1 (i.e., intervention with active feedback for scores of ≤ 4), and post-CDS period 2 (i.e., intervention with active feedback for scores of ≤ 6). Segmented regression analysis with interrupted time series data estimated changes in scores stratified by house staff and non-house staff. Generalized linear models further estimated the modifying effect of the house staff variable. RESULTS Mean scores were 6.2, 6.2, and 6.7 in the pre-CDS, post-CDS 1, and post-CDS 2 periods, respectively (p < 0.05). In the segmented regression analysis, mean scores significantly (p < 0.05) increased when comparing pre-CDS versus post-CDS 2 periods for both house staff (baseline increase, 0.41; 95% CI, 0.17-0.64) and non-house staff (baseline increase, 0.58; 95% CI, 0.34-0.81), showing no differences in effect between the cohorts. The generalized linear model showed significantly higher scores, particularly in the post-CDS 2 period compared with the pre-CDS period (0.44 increase in scores; p < 0.05). The house staff variable did not significantly change estimates in the post-CDS 2 period. CONCLUSION Implementation of active CDS increased overall scores of CT and MRI orders. However, there was no significant difference in effect on scores between house staff and non-house staff.
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Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Ann Emerg Med 2019; 74:285-296. [PMID: 30611639 DOI: 10.1016/j.annemergmed.2018.10.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED). METHODS A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias. RESULTS A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials. CONCLUSION Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.
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18
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Raja AS, Pourjabbar S, Ip IK, Baugh CW, Sodickson AD, O'Leary M, Khorasani R. Impact of a Health Information Technology–Enabled Appropriate Use Criterion on Utilization of Emergency Department CT for Renal Colic. AJR Am J Roentgenol 2019; 212:142-145. [DOI: 10.2214/ajr.18.19966] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Ali S. Raja
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
- Department of Radiology, Brigham and Women's Hospital, Boston, MA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sarvenaz Pourjabbar
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Ivan K. Ip
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
- Department of Radiology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Christopher W. Baugh
- Harvard Medical School, Boston, MA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aaron D. Sodickson
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
- Department of Radiology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Michael O'Leary
- Harvard Medical School, Boston, MA
- Department of Urology, Brigham and Women's Hospital, Boston, MA
| | - Ramin Khorasani
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
- Department of Radiology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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19
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Abstract
Pediatric emergency medicine quality work continues to focus on the National Academies of Sciences, Engineering, and Medicine's 6 domains of quality, with a need for specific emphasis on equity and patient centeredness. Adopting the principles of high-reliability organizations, pediatric emergency departments should become increasing transparent with benchmarking and collaboration across institutions in order to develop an infrastructure for quality and safety to improve the care of pediatric patients in the emergency department.
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Affiliation(s)
- Brandon C Ku
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19146, USA.
| | - James M Chamberlain
- Department of Pediatrics, Division of Emergency Medicine, Children's National Medical Center, George Washington University School of Medicine, 111 Michigan Avenue NW, Washington, DC 20010, USA
| | - Kathy N Shaw
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19146, USA
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20
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Keyworth C, Hart J, Armitage CJ, Tully MP. What maximizes the effectiveness and implementation of technology-based interventions to support healthcare professional practice? A systematic literature review. BMC Med Inform Decis Mak 2018; 18:93. [PMID: 30404638 PMCID: PMC6223001 DOI: 10.1186/s12911-018-0661-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 09/27/2018] [Indexed: 02/02/2023] Open
Abstract
Background Technological support may be crucial in optimizing healthcare professional practice and improving patient outcomes. A focus on electronic health records has left other technological supports relatively neglected. Additionally, there has been no comparison between different types of technology-based interventions, and the importance of delivery setting on the implementation of technology-based interventions to change professional practice. Consequently, there is a need to synthesise and examine intervention characteristics using a methodology suited to identifying important features of effective interventions, and the barriers and facilitators to implementation. Three aims were addressed: to identify interventions with a technological component that are successful at changing professional practice, to determine if and how such interventions are theory-based, and to examine barriers and facilitators to successful implementation. Methods A literature review informed by realist review methods was conducted involving a systematic search of studies reporting either: (1) behavior change interventions that included technology to support professional practice change; or (2) barriers and facilitators to implementation of technological interventions. Extracted data was quantitative and qualitative, and included setting, target professionals, and use of Behaviour Change Techniques (BCTs). The primary outcome was a change in professional practice. A thematic analysis was conducted on studies reporting barriers and facilitators of implementation. Results Sixty-nine studies met the inclusion criteria; 48 (27 randomized controlled trials) reported behavior change interventions and 21 reported practicalities of implementation. The most successful technological intervention was decision support providing healthcare professionals with knowledge and/or person-specific information to assist with patient management. Successful technologies were more likely to operationalise BCTs, particularly “instruction on how to perform the behavior”. Facilitators of implementation included aligning studies with organisational initiatives, ensuring senior peer endorsement, and integration into clinical workload. Barriers included organisational challenges, and design, content and technical issues of technology-based interventions. Conclusions Technological interventions must focus on providing decision support for clinical practice using recognized behavior change techniques. Interventions must consider organizational context, clinical workload, and have clearly defined benefits for improving practice and patient outcomes. Electronic supplementary material The online version of this article (10.1186/s12911-018-0661-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Keyworth
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.
| | - J Hart
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.,Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK
| | - C J Armitage
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
| | - M P Tully
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, M13 9PL, UK
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Undén J, Dalziel SR, Borland ML, Phillips N, Kochar A, Lyttle MD, Bressan S, Cheek JA, Neutze J, Donath S, Hearps S, Oakley E, Dalton S, Gilhotra Y, Babl FE. External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC Med 2018; 16:176. [PMID: 30309392 PMCID: PMC6182797 DOI: 10.1186/s12916-018-1166-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/07/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Clinical decision rules (CDRs) aid in the management of children with traumatic brain injury (TBI). Recently, the Scandinavian Neurotrauma Committee (SNC) has published practical, evidence-based guidelines for children with Glasgow Coma Scale (GCS) scores of 9-15. This study aims to validate these guidelines and to compare them with other CDRs. METHODS A large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, we compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13-15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT. RESULTS The SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1-100.0; 32/32), 97.8% (94.5-99.4; 179/183) and 95% (95% CI 91.6-97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs. CONCLUSION The SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI.
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Affiliation(s)
- Johan Undén
- Department of Operation and Intensive Care, Hallands Hospital, Halmstad, Sweden.,Lund University, Lund, Sweden
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Health, 2 Park Rd, Grafton, Auckland, 1023, New Zealand.,Liggins Institute, University of Auckland, 85 Park Ave, Grafton, Auckland, 1023, New Zealand
| | - Meredith L Borland
- Emergency Department, Princess Margaret Hospital for Children, Roberts Rd, Subiaco, Perth, Western Australia, 6008, Australia.,Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, 6009, Australia
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, 501 Stanley St, South Brisbane, Queensland, 4101, Australia
| | - Amit Kochar
- Emergency Department, Women's & Children's Hospital, Adelaide, 72 King William St, North Adelaide, South Australia, 5006, Australia
| | - Mark D Lyttle
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Emergency Department, Bristol Children's Hospital, Paul O'Gorman Building, Upper Maudlin St, Bristol, BS2 8BJ, UK.,Academic Department of Emergency Care, University of the West of England, Blackberry Hill, Bristol, BS16 1XS, UK
| | - Silvia Bressan
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Women's and Children's Health, University of Padova, Via Giustiniani3, 2, 35128, Padova, Padova, Italy
| | - John A Cheek
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Emergency Department, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, 3186, Australia
| | - Jocelyn Neutze
- Emergency Department, Kidzfirst Middlemore Hospital, 100 Hospital Rd, Auckland, 2025, New Zealand
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, Victoria, 3010, Australia
| | - Stephen Hearps
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, Victoria, 3010, Australia
| | - Sarah Dalton
- Emergency Department, The Children's Hospital at Westmead, 212 Hawkesbury Rd, Westmead, New South Wales, 2145, Australia
| | - Yuri Gilhotra
- Emergency Department, Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, 501 Stanley St, South Brisbane, Queensland, 4101, Australia
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia. .,Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia. .,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, Victoria, 3010, Australia.
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Glover M, Gottumukkala RV, Sanchez Y, Yun BJ, Benzer TI, White BA, Prabhakar AM, Raja AS. Appropriateness of Extremity Magnetic Resonance Imaging Examinations in an Academic Emergency Department Observation Unit. West J Emerg Med 2018; 19:467-473. [PMID: 29760842 PMCID: PMC5942010 DOI: 10.5811/westjem.2018.3.35463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/26/2017] [Accepted: 03/09/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction Emergency departments (ED) and hospitals face increasing challenges related to capacity, throughput, and stewardship of limited resources while maintaining high quality. Appropriate utilization of extremity magnetic resonance imaging (MRI) examinations within the emergency setting is not well known. Therefore, this study aimed to determine indications for and appropriateness of MRI of the extremities for musculoskeletal conditions in the ED observation unit (EDOU). Methods We conducted this institutional review board-approved, retrospective study in a large, quaternary care academic center and Level I trauma center. An institutional database was queried retrospectively to identify all adult patients undergoing an extremity MRI while in the EDOU during the two-year study period from October 2013 through September 2015. We compared clinical history with the American College of Radiology (ACR) Appropriateness Criteria® for musculoskeletal indications. The primary outcome was appropriateness of musculoskeletal MRI exams of the extremities; examinations with an ACR Criteria score of seven or higher were deemed appropriate. Secondary measures included MRI utilization and imaging findings. Results During the study period, 22,713 patients were evaluated in the EDOU. Of those patients, 4,409 had at least one MRI performed, and 88 MRIs met inclusion criteria as musculoskeletal extremity examinations (2% of all patients undergoing an MRI exam in the EDOU during the study period). The most common exams were foot (27, 31%); knee (26, 30%); leg/femur (10, 11%); and shoulder (10, 11%). The most common indications were suspected infection (42, 48%) and acute trauma (23, 26%). Fifty-six percent of exams were performed with intravenous contrast; and 83% (73) of all MRIs were deemed appropriate based on ACR Criteria. The most common reason for inappropriate imaging was lack of performance of radiographs prior to MRI. Conclusion The majority of musculoskeletal extremity MRI examinations performed in the EDOU were appropriate based on ACR Appropriateness Criteria. However, the optimal timing and most-appropriate site for performance of many clinically appropriate musculoskeletal extremity MRIs performed in the EDOU remains unclear. Potential deferral to the outpatient setting may be a preferred population health management strategy.
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Affiliation(s)
- McKinley Glover
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Massachusetts General Physicians Organization, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Ravi V Gottumukkala
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Yadiel Sanchez
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Brian J Yun
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Theodore I Benzer
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Benjamin A White
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Anand M Prabhakar
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Division of Emergency Imaging, Boston, Massachusetts
| | - Ali S Raja
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Isenberg DL, Kissman KM, Salinski EP, Saks MA, Evans LB. Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients. West J Emerg Med 2018; 19:668-674. [PMID: 30013702 PMCID: PMC6040899 DOI: 10.5811/westjem.2018.4.36879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 03/07/2018] [Accepted: 04/09/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction In 2013 the Society for Critical Care Medicine (SCCM) published guidelines for the management of pain and agitation in the intensive care unit (ICU). These guidelines recommend using an analgesia-first strategy in mechanically ventilated patients as well as reducing the use of benzodiazepines. Benzodiazepines increase delirium in ICU patients thereby increasing ICU length of stay. We sought to determine whether a simple educational intervention for emergency department (ED) staff, as well as two simple changes in workflow, would improve adherence to the SCCM guidelines. Methods This was a cohort study that took place from 2014–2016. All patients who were intubated in the ED by an emergency physician (EP) during this time were eligible for inclusion in this study. In January 2015, we began an educational campaign with the ED staff consisting of a series of presentations and online trainings. The impetus for our educational campaign was to have best practices in place for our new emergency medicine residency program starting in July 2016. We made two minor changes in our ED workflow to support this educational objective. First, fentanyl infusions were stocked in the ED. Second, we instituted a medication order set for mechanically ventilated patients. This order set nudged EPs to choose medications consistent with the SCCM guidelines. We then evaluated the use of opioids and benzodiazepines in mechanically ventilated patients from 2014 through 2016 using Fisher’s exact test. All analyses were conducted in the overall sample (n=509) as well as in subgroups after excluding patients with seizures/status epilepticus as their primary admission diagnosis (n=461). Results In 2014 prior to the interventions, 41% of mechanically ventilated patients received an opioid, either as an intravenous (IV) push or IV infusion. In 2015 immediately after the intervention, 71% of patients received an opioid and 64% received an opioid in 2016. The use of benzodiazepine infusions decreased from 22% in 2014 to 7% in 2015 to 1% in 2016. Conclusion A brief educational intervention along with two simple changes in ED workflow can improve compliance with the SCCM guidelines for the management of pain and agitation in mechanically ventilated patients.
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Affiliation(s)
- Derek L Isenberg
- Lewis Katz School of Medicine at Temple University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Katrina M Kissman
- Crozer Chester Medical Center, Department of Emergency Medicine, Upland, Pennsylvania
| | - Ellie P Salinski
- Crozer Chester Medical Center, Department of Emergency Medicine, Upland, Pennsylvania
| | - Mark A Saks
- Crozer Chester Medical Center, Department of Emergency Medicine, Upland, Pennsylvania
| | - Loreen B Evans
- Crozer Chester Medical Center, Department of Emergency Medicine, Upland, Pennsylvania
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Sim EY, Tan DJA, Abdullah HR. The use of computerized physician order entry with clinical decision support reduces practice variance in ordering preoperative investigations: A retrospective cohort study. Int J Med Inform 2017; 108:29-35. [DOI: 10.1016/j.ijmedinf.2017.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/12/2017] [Accepted: 09/26/2017] [Indexed: 12/19/2022]
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Jin DX, McNabb-Baltar JY, Suleiman SL, Wu BU, Khorasani R, Bollen TL, Banks PA, Singh VK. Early Abdominal Imaging Remains Over-Utilized in Acute Pancreatitis. Dig Dis Sci 2017; 62:2894-2899. [PMID: 28840381 DOI: 10.1007/s10620-017-4720-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 08/10/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Early abdominal computed tomography (CT) or magnetic resonance (MR) imaging is common in acute pancreatitis (AP). Guidelines (2007-2013) indicate routine use is unwarranted. AIMS To compare the frequency and evaluate the predictors of early CT/MR utilization for AP between September 2006-2007 (period A) and September 2014-2015 (period B). METHODS AP patients presenting directly to a large academic emergency department were prospectively enrolled during each period. Cases requiring imaging to fulfill diagnostic criteria were excluded. Early CT/MR (within 24 h of presentation) utilization rates were compared using Fisher's exact test. Predictors of early imaging usage were assessed with multivariate logistic regression. RESULTS The cohort included 96 AP cases in period A and 97 in period B. There were no significant differences in patient demographics, comorbidity scores, or AP severity. Period B cases manifested decreased rates of the systemic inflammatory response syndrome (SIRS) during the first 24 h of hospitalization (67% period A vs. 43% period B, p = 0.001). Independent predictors of early imaging included age >60 and SIRS or organ failure on day 1. No significant decrease in early CT/MR usage was observed from period A to B on both univariate (49% period A vs. 40% period B, p = 0.25) and multivariate (OR 1.0 for period B vs. A, 95% CI 0.5-1.9) analysis. CONCLUSIONS In a comparison of imaging practices for AP, there was no significant decrease in early abdominal CT/MR utilization from 2007 to 2015. Quality improvement initiatives specifically targeting early imaging overuse are needed.
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Affiliation(s)
- David X Jin
- Division of Gastroenterology, Hepatology and Endoscopy, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Julia Y McNabb-Baltar
- Division of Gastroenterology, Hepatology and Endoscopy, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Shadeah L Suleiman
- Division of Gastroenterology, Hepatology and Endoscopy, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Bechien U Wu
- Division of Gastroenterology, Pancreatic Disease Center, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Ramin Khorasani
- Department of Radiology, Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter A Banks
- Division of Gastroenterology, Hepatology and Endoscopy, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Pancreatitis Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Weilburg JB, Sistrom CL, Rosenthal DI, Stout MB, Dreyer KJ, Rockett HR, Baron JM, Ferris TG, Thrall JH. Utilization Management of High-Cost Imaging in an Outpatient Setting in a Large Stable Patient and Provider Cohort over 7 Years. Radiology 2017; 284:766-776. [PMID: 28430557 DOI: 10.1148/radiol.2017160968] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To quantify the effect of a comprehensive, long-term, provider-led utilization management (UM) program on high-cost imaging (computed tomography, magnetic resonance imaging, nuclear imaging, and positron emission tomography) performed on an outpatient basis. Materials and Methods This retrospective, 7-year cohort study included all patients regularly seen by primary care physicians (PCPs) at an urban academic medical center. The main outcome was the number of outpatient high-cost imaging examinations per patient per year ordered by the patient's PCP or by any specialist. The authors determined the probability of a patient undergoing any high-cost imaging procedure during a study year and the number of examinations per patient per year (intensity) in patients who underwent high-cost imaging. Risk-adjusted hierarchical models were used to directly quantify the physician component of variation in probability and intensity of high-cost imaging use, and clinicians were provided with regular comparative feedback on the basis of the results. Observed trends in high-cost imaging use and provider variation were compared with the same measures for outpatient laboratory studies because laboratory use was not subject to UM during this period. Finally, per-member per-year high-cost imaging use data were compared with statewide high-cost imaging use data from a major private payer on the basis of the same claim set. Results The patient cohort steadily increased in size from 88 959 in 2007 to 109 823 in 2013. Overall high-cost imaging utilization went from 0.43 examinations per year in 2007 to 0.34 examinations per year in 2013, a decrease of 21.33% (P < .0001). At the same time, similarly adjusted routine laboratory study utilization decreased by less than half that rate (9.4%, P < .0001). On the basis of unadjusted data, outpatient high-cost imaging utilization in this cohort decreased 28%, compared with a 20% decrease in statewide utilization (P = .0023). Conclusion Analysis of high-cost imaging utilization in a stable cohort of patients cared for by PCPs during a 7-year period showed that comprehensive UM can produce a significant and sustained reduction in risk-adjusted per-patient year outpatient high-cost imaging volume. © RSNA, 2017.
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Affiliation(s)
- Jeffrey B Weilburg
- From the Departments of Psychiatry (J.B.W.), Radiology (C.P.S., D.I.R., M.S., K.J.D., J.H.T.), Pathology (J.M.B.), and Medicine (T.F.), Massachusetts General Hospital, Fruit St, Boston, MA 02114; and Massachusetts General Physicians Organization, Boston, Mass (J.B.W., C.P.S., H.R., T.F.)
| | - Christopher L Sistrom
- From the Departments of Psychiatry (J.B.W.), Radiology (C.P.S., D.I.R., M.S., K.J.D., J.H.T.), Pathology (J.M.B.), and Medicine (T.F.), Massachusetts General Hospital, Fruit St, Boston, MA 02114; and Massachusetts General Physicians Organization, Boston, Mass (J.B.W., C.P.S., H.R., T.F.)
| | - Daniel I Rosenthal
- From the Departments of Psychiatry (J.B.W.), Radiology (C.P.S., D.I.R., M.S., K.J.D., J.H.T.), Pathology (J.M.B.), and Medicine (T.F.), Massachusetts General Hospital, Fruit St, Boston, MA 02114; and Massachusetts General Physicians Organization, Boston, Mass (J.B.W., C.P.S., H.R., T.F.)
| | - Markus B Stout
- From the Departments of Psychiatry (J.B.W.), Radiology (C.P.S., D.I.R., M.S., K.J.D., J.H.T.), Pathology (J.M.B.), and Medicine (T.F.), Massachusetts General Hospital, Fruit St, Boston, MA 02114; and Massachusetts General Physicians Organization, Boston, Mass (J.B.W., C.P.S., H.R., T.F.)
| | - Keith J Dreyer
- From the Departments of Psychiatry (J.B.W.), Radiology (C.P.S., D.I.R., M.S., K.J.D., J.H.T.), Pathology (J.M.B.), and Medicine (T.F.), Massachusetts General Hospital, Fruit St, Boston, MA 02114; and Massachusetts General Physicians Organization, Boston, Mass (J.B.W., C.P.S., H.R., T.F.)
| | - Helaine R Rockett
- From the Departments of Psychiatry (J.B.W.), Radiology (C.P.S., D.I.R., M.S., K.J.D., J.H.T.), Pathology (J.M.B.), and Medicine (T.F.), Massachusetts General Hospital, Fruit St, Boston, MA 02114; and Massachusetts General Physicians Organization, Boston, Mass (J.B.W., C.P.S., H.R., T.F.)
| | - Jason M Baron
- From the Departments of Psychiatry (J.B.W.), Radiology (C.P.S., D.I.R., M.S., K.J.D., J.H.T.), Pathology (J.M.B.), and Medicine (T.F.), Massachusetts General Hospital, Fruit St, Boston, MA 02114; and Massachusetts General Physicians Organization, Boston, Mass (J.B.W., C.P.S., H.R., T.F.)
| | - Timothy G Ferris
- From the Departments of Psychiatry (J.B.W.), Radiology (C.P.S., D.I.R., M.S., K.J.D., J.H.T.), Pathology (J.M.B.), and Medicine (T.F.), Massachusetts General Hospital, Fruit St, Boston, MA 02114; and Massachusetts General Physicians Organization, Boston, Mass (J.B.W., C.P.S., H.R., T.F.)
| | - James H Thrall
- From the Departments of Psychiatry (J.B.W.), Radiology (C.P.S., D.I.R., M.S., K.J.D., J.H.T.), Pathology (J.M.B.), and Medicine (T.F.), Massachusetts General Hospital, Fruit St, Boston, MA 02114; and Massachusetts General Physicians Organization, Boston, Mass (J.B.W., C.P.S., H.R., T.F.)
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Maddox TM, Albert NM, Borden WB, Curtis LH, Ferguson TB, Kao DP, Marcus GM, Peterson ED, Redberg R, Rumsfeld JS, Shah ND, Tcheng JE. The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e826-e857. [DOI: 10.1161/cir.0000000000000480] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The learning healthcare system uses health information technology and the health data infrastructure to apply scientific evidence at the point of clinical care while simultaneously collecting insights from that care to promote innovation in optimal healthcare delivery and to fuel new scientific discovery. To achieve these goals, the learning healthcare system requires systematic redesign of the current healthcare system, focusing on 4 major domains: science and informatics, patient-clinician partnerships, incentives, and development of a continuous learning culture. This scientific statement provides an overview of how these learning healthcare system domains can be realized in cardiovascular disease care. Current cardiovascular disease care innovations in informatics, data uses, patient engagement, continuous learning culture, and incentives are profiled. In addition, recommendations for next steps for the development of a learning healthcare system in cardiovascular care are presented.
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Raja AS, Venkatesh AK, Mick N, Zabbo CP, Hasegawa K, Espinola JA, Bittner JC, Camargo CA. "Choosing Wisely" Imaging Recommendations: Initial Implementation in New England Emergency Departments. West J Emerg Med 2017; 18:454-458. [PMID: 28435496 PMCID: PMC5391895 DOI: 10.5811/westjem.2017.1.32677] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/13/2016] [Accepted: 01/13/2017] [Indexed: 12/02/2022] Open
Abstract
Introduction In June 2016, the American College of Emergency Physicians (ACEP) Emergency Quality Network began its Reduce Avoidable Imaging Initiative, designed to “reduce testing and imaging with low risk patients through the implementation of Choosing Wisely recommendations.” However, it is unknown whether New England emergency departments (ED) have already implemented evidence-based interventions to improve adherence to ACEP Choosing Wisely recommendations related to imaging after their initial release in 2013. Our objective was to determine this, as well as whether provider-specific audit and feedback for imaging had been implemented in these EDs. Methods This survey study was exempt from institutional review board review. In 2015, we mailed surveys to 195 hospital-affiliated EDs in all six New England states to determine whether they had implemented Choosing Wisely-focused interventions in 2014. Initial mailings included cover letters denoting the endorsement of each state’s ACEP chapter, and we followed up twice with repeat mailings to non-responders. Data analysis included descriptive statistics and a comparison of state differences using Fisher’s exact test. Results A total of 169/195 (87%) of New England EDs responded, with all individual state response rates >80%. Overall, 101 (60%) of responding EDs had implemented an intervention for at least one Choosing Wisely imaging scenario; 57% reported implementing a specific guideline/policy/clinical pathway and 28% reported implementing a computerized decision support system. The most common interventions were for chest computed tomography (CT) in patients at low risk of pulmonary embolism (47% of EDs) and head CT in patients with minor trauma (45% of EDs). In addition, 40% of EDs had implemented provider-specific audit and feedback, without significant interstate variation (range: 29–55%). Conclusion One year after release of the ACEP Choosing Wisely recommendations, most New England EDs had a guideline/policy/clinical pathway related to at least one of the recommendations. However, only a minority of them were using provider-specific audit and feedback or computerized decision support. Few EDs have embraced the opportunity to implement the multiple evidence-based interventions likely to advance the national goals of improving patient-centered and resource-efficient care.
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Affiliation(s)
- Ali S Raja
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Arjun K Venkatesh
- Yale University School of Medicine, Department of Emergency Medicine and Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Nathan Mick
- Tufts University School of Medicine, Maine Medical Center, Department of Emergency Medicine, Medford, Massachusetts
| | | | - Kohei Hasegawa
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Janice A Espinola
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Jane C Bittner
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A Camargo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
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Tajmir S, Raja AS, Ip IK, Andruchow J, Silveira P, Smith S, Khorasani R. Impact of Clinical Decision Support on Radiography for Acute Ankle Injuries: A Randomized Trial. West J Emerg Med 2017; 18:487-495. [PMID: 28435501 PMCID: PMC5391900 DOI: 10.5811/westjem.2017.1.33053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/31/2016] [Accepted: 01/16/2017] [Indexed: 12/26/2022] Open
Abstract
Introduction While only 15–20% of patients with foot and ankle injuries presenting to urgent care centers have clinically significant fractures, most undergo radiography. We examined the impact of electronic point-of-care clinical decision support (CDS) on adherence to the Ottawa Ankle Rules (OAR), as well as use and yield of foot and ankle radiographs in patients with acute ankle injury. Methods We obtained institutional review board approval for this randomized controlled study performed April 18, 2012—December 15, 2013. All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were randomized to either receive or not receive CDS, based on the OAR and integrated into the physician order-entry system, with feedback at the time of imaging order. If the patient met OAR low-risk criteria, providers were advised against imaging and could either cancel the order or ignore the alert. We identified patients with foot and ankle complaints via ICD-9 billing codes and electronic health records and radiology reports reviewed for those who were eligible. Chi-square was used to compare adherence to the OAR (primary outcome), radiography utilization rate and radiography yield of foot and ankle imaging (secondary outcomes) between the intervention and control groups. Results Of 14,642 patients seen at urgent care during the study period, 613 (4.2%, representing 632 visits) presented with acute ankle injury and were eligible for application of the OAR; 374 (59.2%) of these were seen by control-group providers. In the intervention group, CDS adherence was higher for both ankle (239/258=92.6% vs. 231/374=61.8%, p=0.02) and foot radiography (209/258=81.0% vs. 238/374=63.6%; p<0.01). However, ankle radiography use was higher in the intervention group (166/258=64.3% vs. 183/374=48.9%; p<0.01), while foot radiography use (141/258=54.6% vs. 202/374=54.0%; p=0.95) was not. Radiography yield was also higher in the intervention group (26/307=8.5% vs. 18/385=4.7%; p=0.04). Conclusion Clinical decision support, previously demonstrated to improve guideline adherence for high-cost imaging, can also improve guideline adherence for radiography – as demonstrated by increased OAR adherence and increased imaging yield.
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Affiliation(s)
- Shahein Tajmir
- Harvard Medical School, Boston, Massachusetts.,Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ali S Raja
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ivan K Ip
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - James Andruchow
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Patricia Silveira
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Stacy Smith
- Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ramin Khorasani
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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JOURNAL CLUB: Predictors of Provider Response to Clinical Decision Support: Lessons Learned From the Medicare Imaging Demonstration. AJR Am J Roentgenol 2016; 208:351-357. [PMID: 27897445 DOI: 10.2214/ajr.16.16373] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The efficacy of imaging clinical decision support (CDS) varies. Our objective was to identify CDS factors contributing to imaging order cancellation or modification. SUBJECTS AND METHODS This pre-post study was performed across four institutions participating in the Medicare Imaging Demonstration. The intervention was CDS at order entry for selected outpatient imaging procedures. On the basis of the information entered, computerized alerts indicated to providers whether orders were not covered by guidelines, appropriate, of uncertain appropriateness, or inappropriate according to professional society guidelines. Ordering providers could override or accept CDS. We considered actionable alerts to be those that could generate an immediate order behavior change in the ordering physician (i.e., cancellation of inappropriate orders or modification of orders of uncertain appropriateness that had a recommended alternative). Chi-square and logistic regression identified predictors of order cancellation or modification after an alert. RESULTS A total of 98,894 radiology orders were entered (83,114 after the intervention). Providers ignored 98.9%, modified 1.1%, and cancelled 0.03% of orders in response to alerts. Actionable alerts had a 10 fold higher rate of modification (8.1% vs 0.7%; p < 0.0001) or cancellation (0.2% vs 0.02%; p < 0.0001) orders compared with nonactionable alerts. Orders from institutions with preexisting imaging CDS had a sevenfold lower rate of cancellation or modification than was seen at sites with newly implemented CDS (1.4% vs 0.2%; p < 0.0001). In multivariate analysis, actionable alerts were 12 times more likely to result in order cancellation or modification. Orders at sites with preexisting CDS were 7.7 times less likely to be cancelled or modified (p < 0.0001). CONCLUSION Using results from the Medicare Imaging Demonstration project, we identified potential factors that were associated with CDS effect on provider imaging ordering; these findings may have implications for future design of such computerized systems.
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Huang ES, Nathan AG, Cooper JM, Lee SM, Shin N, John PM, Dale W, Col NF, Meltzer DO, Chin MH. Impact and Feasibility of Personalized Decision Support for Older Patients with Diabetes: A Pilot Randomized Trial. Med Decis Making 2016; 37:611-617. [PMID: 27311651 DOI: 10.1177/0272989x16654142] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Diabetes guidelines recommend individualizing glycemic goals (A1C) for older patients. The aim of this study was to assess a personalized Web-based decision support tool. METHODS We randomized physicians and their patients with type 2 diabetes (≥65 years of age) to a support tool or educational pamphlet (75:25 patients). Prior to a visit, intervention patients interacted with the tool, which provided personalized risk predictions and elicited treatment preferences. Main outcomes included 1) patient-doctor communication, 2) decisional conflict, 3) changes in goals, and 4) intervention acceptability. RESULTS We did not find significant differences in proportions of patients who had an A1C discussion (91% intervention v. 76% control; P = 0.19). Intervention patients had larger declines in the informed subscale of decisional conflict (-20 v. 0, respectively; P = 0.04). There were no significant differences in proportions of patients with changes in goals (49% v. 28%, respectively; P = 0.08). Most intervention patients reported that the tool was easy to use (91%) and helped them to communicate (84%). A limitation was that this was a pilot trial at one academic institution. CONCLUSIONS Web-based decision support tools may be a practical approach to facilitating the personalization of goals for chronic conditions. TRIAL REGISTRATION NCT02169999 ( https://clinicaltrials.gov/show/NCT02169999 ).
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Affiliation(s)
- Elbert S Huang
- Section of General Internal Medicine, University of Chicago, Chicago, IL (ESH, AGN, JMC, NS, PMJ, MHC)
| | - Aviva G Nathan
- Section of General Internal Medicine, University of Chicago, Chicago, IL (ESH, AGN, JMC, NS, PMJ, MHC)
| | - Jennifer M Cooper
- Section of General Internal Medicine, University of Chicago, Chicago, IL (ESH, AGN, JMC, NS, PMJ, MHC)
| | - Sang Mee Lee
- Department of Public Health Sciences, University of Chicago, Chicago, IL (SML)
| | - Na Shin
- Section of General Internal Medicine, University of Chicago, Chicago, IL (ESH, AGN, JMC, NS, PMJ, MHC)
| | - Priya M John
- Section of General Internal Medicine, University of Chicago, Chicago, IL (ESH, AGN, JMC, NS, PMJ, MHC)
| | - William Dale
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, IL (WD)
| | - Nananda F Col
- Shared Decision Making Resources, Georgetown, ME (NFC)
| | - David O Meltzer
- Section of Hospital Medicine, University of Chicago, Chicago, IL (DOM)
| | - Marshall H Chin
- Section of General Internal Medicine, University of Chicago, Chicago, IL (ESH, AGN, JMC, NS, PMJ, MHC)
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Genes N, Kim MS, Thum FL, Rivera L, Beato R, Song C, Soriano J, Kannry J, Baumlin K, Hwang U. Usability Evaluation of a Clinical Decision Support System for Geriatric ED Pain Treatment. Appl Clin Inform 2016; 7:128-42. [PMID: 27081412 DOI: 10.4338/aci-2015-08-ra-0108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/05/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Older adults are at risk for inadequate emergency department (ED) pain care. Unrelieved acute pain is associated with poor outcomes. Clinical decision support systems (CDSS) hold promise to improve patient care, but CDSS quality varies widely, particularly when usability evaluation is not employed. OBJECTIVE To conduct an iterative usability and redesign process of a novel geriatric abdominal pain care CDSS. We hypothesized this process would result in the creation of more usable and favorable pain care interventions. METHODS Thirteen emergency physicians familiar with the Electronic Health Record (EHR) in use at the study site were recruited. Over a 10-week period, 17 1-hour usability test sessions were conducted across 3 rounds of testing. Participants were given 3 patient scenarios and provided simulated clinical care using the EHR, while interacting with the CDSS interventions. Quantitative System Usability Scores (SUS), favorability scores and qualitative narrative feedback were collected for each session. Using a multi-step review process by an interdisciplinary team, positive and negative usability issues in effectiveness, efficiency, and satisfaction were considered, prioritized and incorporated in the iterative redesign process of the CDSS. Video analysis was used to determine the appropriateness of the CDS appearances during simulated clinical care. RESULTS Over the 3 rounds of usability evaluations and subsequent redesign processes, mean SUS progressively improved from 74.8 to 81.2 to 88.9; mean favorability scores improved from 3.23 to 4.29 (1 worst, 5 best). Video analysis revealed that, in the course of the iterative redesign processes, rates of physicians' acknowledgment of CDS interventions increased, however most rates of desired actions by physicians (such as more frequent pain score updates) decreased. CONCLUSION The iterative usability redesign process was instrumental in improving the usability of the CDSS; if implemented in practice, it could improve geriatric pain care. The usability evaluation process led to improved acknowledgement and favorability. Incorporating usability testing when designing CDSS interventions for studies may be effective to enhance clinician use.
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Affiliation(s)
- Nicholas Genes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Min Soon Kim
- Department of Health Management & Informatics, University of Missouri School of Medicine, Columbia, MO; Informatics Institute, University of Missouri, Columbia, MO
| | - Frederick L Thum
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Laura Rivera
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Rosemary Beato
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Carolyn Song
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Jared Soriano
- Information Technology, Mount Sinai Health System , New York, NY
| | - Joseph Kannry
- Information Technology, Mount Sinai Health System, New York, NY; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kevin Baumlin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Ula Hwang
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research, Education and Clinical Center, James J Peters VAMC, Bronx, NY
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The Value of Imaging Part II: Value beyond Image Interpretation. Acad Radiol 2016; 23:23-9. [PMID: 26683509 DOI: 10.1016/j.acra.2015.09.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/09/2015] [Accepted: 09/20/2015] [Indexed: 12/21/2022]
Abstract
Although image interpretation is an essential part of radiologists' value, there are other ways in which we contribute to patient care. Part II of the value of imaging series reviews current initiatives that demonstrate value beyond the image interpretation. Standardizing processes, reducing the radiation dose of our examinations, clarifying written reports, improving communications with patients and providers, and promoting appropriate imaging through decision support are all ways we can provide safer, more consistent, and higher quality care. As payers and policy makers push to drive value, research that demonstrates the value of these endeavors, or lack thereof, will become increasingly sought after and supported.
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Melnick ER, Shafer K, Rodulfo N, Shi J, Hess EP, Wears RL, Qureshi RA, Post LA. Understanding Overuse of Computed Tomography for Minor Head Injury in the Emergency Department: A Triangulated Qualitative Study. Acad Emerg Med 2015; 22:1474-83. [PMID: 26568523 DOI: 10.1111/acem.12824] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/20/2015] [Accepted: 06/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance. OBJECTIVES The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury. METHODS This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150 hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus. RESULTS Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT. CONCLUSIONS Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury.
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Affiliation(s)
- Edward R. Melnick
- Department of Emergency Medicine; Yale School of Medicine; New Haven CT
| | - Katherine Shafer
- Department of Emergency Medicine; Yale School of Medicine; New Haven CT
| | - Nayeli Rodulfo
- Department of Emergency Medicine; Yale School of Medicine; New Haven CT
| | - Joyce Shi
- Department of Emergency Medicine; Yale University; New Haven CT
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
| | - Robert L. Wears
- Department of Emergency Medicine; the University of Florida-Jacksonville; Jacksonville FL
| | - Rija A. Qureshi
- Department of Emergency Medicine; Ziauddin Medical University; Karachi Pakistan
| | - Lori A. Post
- Department of Emergency Medicine; Yale School of Medicine; New Haven CT
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Blackmore CC, Castro A. Improving the Quality of Imaging in the Emergency Department. Acad Emerg Med 2015; 22:1385-92. [PMID: 26568040 DOI: 10.1111/acem.12816] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 07/06/2015] [Indexed: 11/29/2022]
Abstract
Imaging is critical for the care of emergency department (ED) patients. However, much of the imaging performed for acute care today is overutilization, creating substantial cost without significant benefit. Further, the value of imaging is not easily defined, as imaging only affects outcomes indirectly, through interaction with treatment. Improving the quality, including appropriateness, of emergency imaging requires understanding of how imaging contributes to patient care. The six-tier efficacy hierarchy of Fryback and Thornbury enables understanding of the value of imaging on multiple levels, ranging from technical efficacy to medical decision-making and higher-level patient and societal outcomes. The imaging efficacy hierarchy also allows definition of imaging quality through the Institute of Medicine (IOM)'s quality domains of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability and provides a foundation for quality improvement. In this article, the authors elucidate the Fryback and Thornbury framework to define the value of imaging in the ED and to relate emergency imaging to the IOM quality domains.
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Affiliation(s)
- C. Craig Blackmore
- The Center for Healthcare Improvement Science and Department of Radiology; Virginia Mason Medical Center; Seattle WA
| | - Alexandra Castro
- The Department of Emergency Medicine; University of Pittsburgh; Pittsburgh PA
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Sabbatini AK, Merck LH, Froemming AT, Vaughan W, Brown MD, Hess EP, Applegate KE, Comfere NI. Optimizing Patient-centered Communication and Multidisciplinary Care Coordination in Emergency Diagnostic Imaging: A Research Agenda. Acad Emerg Med 2015; 22:1427-34. [PMID: 26575785 DOI: 10.1111/acem.12826] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 07/06/2015] [Indexed: 12/17/2022]
Abstract
Patient-centered emergency diagnostic imaging relies on efficient communication and multispecialty care coordination to ensure optimal imaging utilization. The construct of the emergency diagnostic imaging care coordination cycle with three main phases (pretest, test, and posttest) provides a useful framework to evaluate care coordination in patient-centered emergency diagnostic imaging. This article summarizes findings reached during the patient-centered outcomes session of the 2015 Academic Emergency Medicine consensus conference "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The primary objective was to develop a research agenda focused on 1) defining component parts of the emergency diagnostic imaging care coordination process, 2) identifying gaps in communication that affect emergency diagnostic imaging, and 3) defining optimal methods of communication and multidisciplinary care coordination that ensure patient-centered emergency diagnostic imaging. Prioritized research questions provided the framework to define a research agenda for multidisciplinary care coordination in emergency diagnostic imaging.
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Affiliation(s)
| | - Lisa H. Merck
- Department of Emergency Medicine; Brown University; Providence RI
- Department of Diagnostic Imaging; Brown University; Providence RI
| | | | | | - Michael D. Brown
- Department of Emergency Medicine; Michigan State University; Grand Rapids MI
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic; Rochester MN
- Knowledge and Evaluation Research Unit; Division of Healthcare Policy Research; Department of Health Services Research; Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery; Mayo Clinic; Rochester MN
| | - Kimberly E. Applegate
- Department of Radiology and Imaging Sciences; Emory University School of Medicine; Atlanta GA
| | - Nneka I. Comfere
- Department of Dermatology; Laboratory Medicine & Pathology; Mayo Clinic; Rochester MN
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Silveira PC, Ip IK, Sumption S, Raja AS, Tajmir S, Khorasani R. Impact of a clinical decision support tool on adherence to the Ottawa Ankle Rules. Am J Emerg Med 2015; 34:412-8. [PMID: 26682677 DOI: 10.1016/j.ajem.2015.11.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE The objective of the study is to determine impact of a clinical decision support (CDS) tool on documented adherence to the Ottawa Ankle Rules (OAR) and utilization and yield of ankle/foot radiography, for emergency department patients with acute ankle injury. METHODS This is a before-and-after intervention study conducted at a 793-bed, quaternary care, academic hospital from August 2012 to October 2013. Emergency department visits from adults with acute ankle injury 6 months before and 8 months after the intervention were included. The intervention embedded the OAR into a CDS tool integrated with a computerized physician order entry system, which had data capture capability and provided feedback at the time of ankle/foot radiography order. Primary outcome was rate of documented adherence to OAR. Secondary outcomes were utilization and yield (clinically significant fracture rates among patients with acute ankle injuries) of ankle/foot radiography. RESULTS The study population included 460 visits; 205 (44.6%) occurred preintervention. After intervention, documented OAR adherence increased from 55.9% (229/410) to 95.7% (488/510; P < .001). Utilization remained stable for ankle (77.5%; P = .800) and foot (48.6%; P = .514) radiography. Yield remained stable for ankle (17.8%; P = .891) and foot (19.8%; P = .889) radiography. DISCUSSION Lack of documentation of key clinical data may hamper provider communication, delay care coordination, and result in legal liability. By embedding the OAR into a CDS tool, we achieved the same rate of documented adherence as previous onerous educational implementations while automating data collection/retrieval. In summary, implementation of the OAR into a CDS tool was associated with an increase in documented adherence to the OAR.
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Affiliation(s)
- Patricia C Silveira
- Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Ivan K Ip
- Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Siobhan Sumption
- Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Ali S Raja
- Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Shahein Tajmir
- Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Ramin Khorasani
- Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Janke AT, Overbeek DL, Kocher KE, Levy PD. Exploring the Potential of Predictive Analytics and Big Data in Emergency Care. Ann Emerg Med 2015. [PMID: 26215667 DOI: 10.1016/j.annemergmed.2015.06.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Clinical research often focuses on resource-intensive causal inference, whereas the potential of predictive analytics with constantly increasing big data sources remains largely unexplored. Basic prediction, divorced from causal inference, is much easier with big data. Emergency care may benefit from this simpler application of big data. Historically, predictive analytics have played an important role in emergency care as simple heuristics for risk stratification. These tools generally follow a standard approach: parsimonious criteria, easy computability, and independent validation with distinct populations. Simplicity in a prediction tool is valuable, but technological advances make it no longer a necessity. Emergency care could benefit from clinical predictions built using data science tools with abundant potential input variables available in electronic medical records. Patients' risks could be stratified more precisely with large pools of data and lower resource requirements for comparing each clinical encounter to those that came before it, benefiting clinical decisionmaking and health systems operations. The largest value of predictive analytics comes early in the clinical encounter, in which diagnostic and prognostic uncertainty are high and resource-committing decisions need to be made. We propose an agenda for widening the application of predictive analytics in emergency care. Throughout, we express cautious optimism because there are myriad challenges related to database infrastructure, practitioner uptake, and patient acceptance. The quality of routinely compiled clinical data will remain an important limitation. Complementing big data sources with prospective data may be necessary if predictive analytics are to achieve their full potential to improve care quality in the emergency department.
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Affiliation(s)
| | - Daniel L Overbeek
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Phillip D Levy
- Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University, Detroit, MI
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Abstract
OBJECTIVE. Falls are a common cause of emergency department (ED) visits in the United States. We evaluated trends in CT utilization for adult fall patients in the United States from 2001 to 2010. MATERIALS AND METHODS. Using the National Hospital Ambulatory Medical Care Survey, we identified all visits from 2001 to 2010 of adult patients presenting to EDs after falls. This database surveys approximately 500 EDs annually for 4 weeks, providing national estimates on ED resource utilization and outcomes. We studied trends in CT utilization and proportion of visits with life-threatening conditions (intracranial hemorrhage, organ laceration, axial skeletal fractures) after falls. We also studied the association between CT utilization rates and demographic characteristics and admission status. RESULTS. A total of 22,166 unweighted observations representing 73,241,368 visits were identified. The proportion of adult fall patient visits during which CT was performed increased from 11.4% in 2001 to 28.0% in 2010 (p < 0.0001), whereas the proportion of adult fall visits with life-threatening conditions increased from 5.7% to 8.2% (p < 0.0001). On adjusted analysis (adjusting for life-threatening condition and demographic variables), each successive year was independently associated with CT utilization (odds ratio, 1.21 [95% CI, 1.21-1.21]). The odds of CT utilization in 2010 compared with 2001 were 2.62 (95% CI, 2.61-2.62). CONCLUSION. There was a 2.5-fold increase in CT utilization among adult fall patient visits from 2001 to 2010. When demographic and clinical variables were controlled for, increasing year was independently associated with CT utilization. These findings suggest that CT may be overutilized among adult fall patients.
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Goldzweig CL, Orshansky G, Paige NM, Miake-Lye IM, Beroes JM, Ewing BA, Shekelle PG. Electronic health record-based interventions for improving appropriate diagnostic imaging: a systematic review and meta-analysis. Ann Intern Med 2015; 162:557-65. [PMID: 25894025 DOI: 10.7326/m14-2600] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND One driver of increasing health care costs is the use of radiologic imaging procedures. More appropriate use could improve quality and reduce costs. PURPOSE To review interventions that use the computerized clinical decision-support (CCDS) capabilities of electronic health records to improve appropriate use of diagnostic radiologic test ordering. DATA SOURCES English-language articles in PubMed from 1995 to September 2014 and searches in Web of Science and PubMed of citations related to key articles. STUDY SELECTION 23 studies, including 3 randomized trials, 7 time-series studies, and 13 pre-post studies that assessed the effect of CCDS on diagnostic radiologic test ordering in adults. DATA EXTRACTION 2 independent reviewers extracted data on functionality, study outcomes, and context and assessed the quality of included studies. DATA SYNTHESIS Thirteen studies provided moderate-level evidence that CCDS improves appropriateness (effect size, -0.49 [95% CI, -0.71 to -0.26]) and reduces use (effect size, -0.13 [CI, -0.23 to -0.04]). Interventions with a "hard stop" that prevents a clinician from overriding the CCDS without outside consultation, as well as interventions in integrated care delivery systems, may be more effective. Harms have rarely been assessed but include decreased ordering of appropriate tests and physician dissatisfaction. LIMITATION Potential for publication bias, insufficient reporting of harms, and poor description of context and implementation. CONCLUSION Computerized clinical decision support integrated with the electronic health record can improve appropriate use of diagnostic radiology by a moderate amount and decrease use by a small amount. Before widespread adoption can be recommended, more data are needed on potential harms. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs. (PROSPERO registration number: CRD42014007469).
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Affiliation(s)
- Caroline Lubick Goldzweig
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Greg Orshansky
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Neil M. Paige
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Isomi M. Miake-Lye
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Jessica M. Beroes
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Brett A. Ewing
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Paul G. Shekelle
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
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Quon JS, Glikstein R, Lim CS, Schwarz BA. Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis. Emerg Radiol 2015; 22:521-5. [DOI: 10.1007/s10140-015-1314-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
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Landman AB. The Potential for Clinical Decision Support to Improve Emergency Care. Ann Emerg Med 2015; 66:521-2. [PMID: 25843426 DOI: 10.1016/j.annemergmed.2015.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Adam B Landman
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Partners Information Systems, Wellesley, MA.
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Journal club: Requiring clinical justification to override repeat imaging decision support: impact on CT use. AJR Am J Roentgenol 2015; 203:W482-90. [PMID: 25341162 DOI: 10.2214/ajr.14.13017] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the impact of requiring clinical justification to override decision support alerts on repeat use of CT. SUBJECTS AND METHODS This before and after intervention study was conducted at a 793-bed tertiary hospital with computerized physician order entry and clinical decision support systems. When a CT order is placed, decision support alerts the orderer if the patient's same body part has undergone CT within the past 90 days. The study cohort included all 28,420 CT orders triggering a repeat alert in 2010. The intervention required clinical justification, selected from a predetermined menu, to override repeat CT decision support alerts to place a CT order; otherwise the order could not be placed and was dropped. The primary outcome, dropped repeat CT orders, was analyzed using three methods: chi-square tests to compare proportions dropped before and after intervention; multiple logistic regression tests to control for orderer, care setting, and patient factors; and statistical process control for temporal trends. RESULTS The repeat CT order drop rate had an absolute increase of 1.4%; 6.1% (682/11,230) before to 7.5% (1290/17,190) after intervention, which was a 23% relative change (7.5 - 6.1)/6.1 × 100 = 23%; p < 0.0001). Orders were dropped more often after intervention (odds ratio, 1.3; 95% CI, 1.1-1.4; p < 0.0001). Statistical control analysis supported the association between the increase in the drop rate with intervention rather than underlying trends. CONCLUSION Adding a requirement for clinical justification to override alerts modestly but significantly improves the impact of repeat CT decision support (23% relative change), with the overall effect of preventing one in 13 repeat CT orders.
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Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med 2014; 33:320-5. [PMID: 25572644 DOI: 10.1016/j.ajem.2014.11.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/31/2014] [Accepted: 11/03/2014] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Reduction of unnecessary head computed tomographies (CTs) in patients with mild traumatic brain injury (MTBI) was recently endorsed by American College of Emergency Physicians (ACEP) in the "Choosing Wisely" campaign. We examined the impact of computerized clinical decision support (CDS) on head CT utilization in MTBI emergency department (ED) visits. METHODS We conducted a 2-year cohort study at a level 1 trauma center and compared our results with the National Hospital Ambulatory Medical Care Survey from 2009 to 2010. All adult patients discharged from the ED with MTBI-associated diagnoses were included. After a baseline observation period at our institution, real-time CDS was implemented. Based upon the clinical history entered, low utility orders triggered an alert to clinicians, suggesting imaging studies might not adhere to evidence-based guidelines. Clinicians could cancel the order or ignore the alert. Primary outcome was intensity of head CT use in MTBI ED visits. Secondary outcomes included rates of delayed imaging and delays in diagnosing radiologically significant findings. χ(2), logistic regression, and process control chart assessed preintervention and postintervention differences. RESULTS In study patients, 58.1% of MTBI-related visits resulted in head CT preintervention vs 50.3% postintervention (13.4% relative decrease, P = .005), a change not detected in controls (73.3% vs 76.9%, P = .272). Study cohort patients not receiving a head CT during their index visit were neither more nor less likely to receive one in the subsequent 7 days (6.7% preintervention vs 9.4% postintervention, P = .231). Rates of delayed diagnosis of radiologically significant findings were unchanged (0% vs 0%). CONCLUSIONS Evidence-based CDS can reduce low utility imaging for MTBI.
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Affiliation(s)
- Ivan K Ip
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Ali S Raja
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Anurag Gupta
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James Andruchow
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Aaron Sodickson
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ramin Khorasani
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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