Physicians, information technology, and health care systems: a journey, not a destination

We Ask and Listen: A Group-Wide Retrospective Survey on Satisfaction with Digital Medication Software

Purpose

Computerized physician order entry (CPOE) and clinical decision support systems (CDSS) are used internationally since the 1980s. These systems reduce costs, enhance drug therapy safety, and improve quality of care. A few years ago, there was a growing effort to digitize the healthcare sector in Germany. Implementing such systems like CPOE-CDSS requires training for effective adoption and, more important, acceptance by the users. Potential improvements for the software and implementation process can be derived from the users' perspective. The implementation process is globally relevant and applicable across professions due to the constant advancement of digitalization. The study assessed the implementation of medication software and overall satisfaction.

Methods

In an anonymous voluntary online survey, physicians and nursing staff were asked about their satisfaction with the new CPOE-CDSS. The survey comprised single-choice queries on a Likert scale, categorizing into general information, digital medication administration, drug safety, and software introduction. In addition multiple-choice questions are mentioned. Data analysis was performed using Microsoft Office Excel 2016 and GraphPad PRISM 9.5.0.

Results

Nurses and physicians' satisfaction with the new software increased with usage hours. The software's performance and loading times have clearly had a negative impact, which leads to a low satisfaction of only 20% among physicians and 17% among nurses. 53% of nurses find the program's training period unsuitable for their daily use, while 57% of physicians approve the training's scope for their professional group. Both professions agree that drug-related problems are easier to detect using CPOE-CDSS, with 76% of nurses and 75% of physicians agreeing. The study provides unbiased feedback on software implementation.

Conclusion

In conclusion, digitizing healthcare requires managing change, effective training, and addressing software functionality concerns to ensure improved medication safety and streamlined processes. Interfaces, performance optimization, and training remain crucial for software acceptance and effectiveness.

Role of Artificial Intelligence within the Telehealth Domain

Objectives : This paper provides a discussion about the potential scope of applicability of Artificial Intelligence methods within the telehealth domain. These methods are focussed on clinical needs and provide some insight to current directions, based on reports of recent advances.

Methods : Examples of telehealth innovations involving Artificial Intelligence to support or supplement remote health care delivery were identified from recent literature by the authors, on the basis of expert knowledge. Observations from the examples were synthesized to yield an overview of contemporary directions for the perceived role of Artificial Intelligence in telehealth.

Results : Two major focus areas for related contemporary directions were established. These were first, quality improvement for existing clinical practice and service delivery, and second, the development and support of new models of care. Case studies from each focus area have been chosen for illustration purposes.

Conclusion : Examples of the role of Artificial Intelligence in delivery of health care remotely include use of tele-assessment, tele-diagnosis, tele-interactions, and tele-monitoring. Further developments of underlying algorithms and validation of methods will be required for wider adoption. Certain key social and ethical considerations also need consideration more generally in the health system, as Artificial-Intelligence-enabled-telehealth becomes more commonplace.

Bridging clinical researcher perceptions and health IT realities: A case study of stakeholder creep

PURPOSE

We present a case report detailing a challenge in health information technology (HIT) project implementations we term "stakeholder creep": not thoroughly identifying which stakeholders need to be involved and why before starting a project, consequently not understanding the true effort, skill sets, social capital, and time required to complete the project.

METHODS

A root cause analysis was performed post-implementation to understand what led to stakeholder creep. HIT project stakeholders were given a questionnaire to comment on these misconceptions and a proposed implementation tool to help mitigate stakeholder creep.

FINDINGS

Stakeholder creep contributed to an unexpected increase in time (3-month delayed go-live) and effort (68% over expected HIT work hours). Four main clinician/researcher misconceptions were identified that contributed to the development of stakeholder creep: 1) that EHR IT is a single group; 2) that all EHR IT members know the entire EHR functionality; 3) that changes to an EHR need the input of just a single EHR IT member; and 4) that the technological complexity of a project mirrors the clinical complexity. HIT project stakeholders similarly perceived clinicians/researchers to hold these misconceptions. The proposed stakeholder planning tool was perceived to be feasible and helpful.

CONCLUSIONS

Stakeholder creep can negatively affect HIT project implementations. Projects may be susceptible to stakeholder creep when clinicians/researchers hold misconceptions related to HIT organization and processes. Implementation tools, such as the proposed stakeholder checklist, could be helpful in preempting and mitigating the effect of stakeholder creep.

Paving the COWpath: data-driven design of pediatric order sets

OBJECTIVE

Evidence indicates that users incur significant physical and cognitive costs in the use of order sets, a core feature of computerized provider order entry systems. This paper develops data-driven approaches for automating the construction of order sets that match closely with user preferences and workflow while minimizing physical and cognitive workload.

MATERIALS AND METHODS

We developed and tested optimization-based models embedded with clustering techniques using physical and cognitive click cost criteria. By judiciously learning from users' actual actions, our methods identify items for constituting order sets that are relevant according to historical ordering data and grouped on the basis of order similarity and ordering time. We evaluated performance of the methods using 47,099 orders from the year 2011 for asthma, appendectomy and pneumonia management in a pediatric inpatient setting.

RESULTS

In comparison with existing order sets, those developed using the new approach significantly reduce the physical and cognitive workload associated with usage by 14-52%. This approach is also capable of accommodating variations in clinical conditions that affect order set usage and development.

DISCUSSION

There is a critical need to investigate the cognitive complexity imposed on users by complex clinical information systems, and to design their features according to 'human factors' best practices. Optimizing order set generation using cognitive cost criteria introduces a new approach that can potentially improve ordering efficiency, reduce unintended variations in order placement, and enhance patient safety.

CONCLUSIONS

We demonstrate that data-driven methods offer a promising approach for designing order sets that are generalizable, data-driven, condition-based, and up to date with current best practices.

Long-term care and health information technology: opportunities and responsibilities for long-term and post-acute care providers

Long-term and post-acute care providers (LTPAC) need to understand the multiple aspects of health information technology (HIT) in the context of health systems transformation in order to be a viable participant. The issues with moving to HIT are not just technical and funding, but include legal and policy, technical and business operations, and very significantly, governance. There are many unanswered questions. However, changes in payment methodologies, service delivery models, consumer expectations, and regulatory requirements necessitate that LTPAC providers begin their journey.

Embedding time-limited laboratory orders within computerized provider order entry reduces laboratory utilization

OBJECTIVES

To test the hypothesis that limits on repeating laboratory studies within computerized provider order entry decrease laboratory utilization.

DESIGN

Cohort study with historical controls.

SETTING

A 20-bed PICU in a freestanding, quaternary care, academic children's hospital.

PATIENTS

This study included all patients admitted to the pediatric ICU between January 1, 2008, and December 31, 2009. A total of 818 discharges were evaluated prior to the intervention (January 1, 2008, through December 31, 2008) and 1,021 patient discharges were evaluated postintervention (January 1, 2009, through December 31, 2009).

INTERVENTION

A computerized provider order entry rule limited the ability to schedule repeating complete blood cell counts, chemistry, and coagulation studies to a 24-hour interval in the future. The time limit was designed to ensure daily evaluation of the utility of each test.

MEASUREMENTS AND MAIN RESULTS

Initial analysis with t tests showed significant decreases in tests per patient day in the postintervention period (complete blood cell counts: 1.5 ± 0.1 to 1.0 ± 0.1; chemistry: 10.6 ± 0.9 to 6.9 ± 0.6; coagulation: 3.3 ± 0.4 to 1.7 ± 0.2; p < 0.01, all variables vs. preintervention period). Even after incorporating a trend toward decreasing laboratory utilization in the preintervention period into our regression analysis, the intervention decreased complete blood cell counts (p = 0.007), chemistry (p = 0.049), and coagulation (p = 0.001) tests per patient day.

CONCLUSIONS

Limits on laboratory orders within the context of computerized provider order entry decreased laboratory utilization without adverse affects on mortality or length of stay. Broader application of this strategy might decrease costs, the incidence of iatrogenic anemia, and catheter-associated bloodstream infections.

Data-driven order set generation and evaluation in the pediatric environment

Order sets as part of the Computerized Provider Order Entry (CPOE) system can improve care delivery through allowing faster and easier physician order entry guided by known best practices. This study examines current utilization patterns of order sets and "a la carte" orders in a pediatric environment with a preliminary investigation of methods to automate the creation and modification of order sets using historical ordering data. We examine the current usage of order sets associated with Asthma Minor and Appendectomy Minor patients to understand how physicians are utilizing order sets, and how order set usage is associated with the time of ordering and characteristics of order sets. K-means clustering was applied to orders to generate evidence-based order sets that are learned from historical hospital data. We demonstrate that coverage rate of order sets and ordering efficiency can be increased through modifications of existing sets and creation of new sets.

Development and validation of a survey instrument for assessing prescribers' perception of computerized drug-drug interaction alerts

OBJECTIVE

To develop a theoretically informed and empirically validated survey instrument for assessing prescribers' perception of computerized drug-drug interaction (DDI) alerts.

MATERIALS AND METHODS

The survey is grounded in the unified theory of acceptance and use of technology and an adapted accident causation model. Development of the instrument was also informed by a review of the extant literature on prescribers' attitude toward computerized medication safety alerts and common prescriber-provided reasons for overriding. To refine and validate the survey, we conducted a two-stage empirical validation study consisting of a pretest with a panel of domain experts followed by a field test among all eligible prescribers at our institution.

RESULTS

The resulting survey instrument contains 28 questionnaire items assessing six theoretical dimensions: performance expectancy, effort expectancy, social influence, facilitating conditions, perceived fatigue, and perceived use behavior. Satisfactory results were obtained from the field validation; however, a few potential issues were also identified. We analyzed these issues accordingly and the results led to the final survey instrument as well as usage recommendations.

DISCUSSION

High override rates of computerized medication safety alerts have been a prevalent problem. They are usually caused by, or manifested in, issues of poor end user acceptance. However, standardized research tools for assessing and understanding end users' perception are currently lacking, which inhibits knowledge accumulation and consequently forgoes improvement opportunities. The survey instrument presented in this paper may help fill this methodological gap.

CONCLUSION

We developed and empirically validated a survey instrument that may be useful for future research on DDI alerts and other types of computerized medication safety alerts more generally.

Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study

BACKGROUND

Although several types of computerized provider order entry (CPOE)-related errors may occur, errors related to inconsistent information within the same prescription (ie, mismatch between the structured template and the associated free-text field) have not been described, to our knowledge. We determined the nature and frequency of such errors and identified their potential predictive variables.

METHODS

In this prospective study, we enrolled pharmacists to report prescriptions containing inconsistent communication over a 4-month period at a tertiary care facility. We also electronically retrieved all prescriptions written during the study period containing any comments in the free-text field and then randomly selected 500 for manual review to determine inconsistencies between free-text and structured fields. Of these, prescriptions without inconsistencies were categorized as controls. Data on potentially predictive variables from reported and unreported errors and controls were collected. For all inconsistencies, we determined their nature (eg, drug dosage or administration schedule) and potential harm and used multivariate logistic regression models to identify factors associated with errors and harm.

RESULTS

Of 55 992 new prescriptions, 532 (0.95%) were reported to contain inconsistent communication, a rate comparable to that obtained from the unreported group. Drug dosage was the most common inconsistent element among both groups. Certain medications were more likely associated with errors, as was the inpatient setting (odds ratio, 3.30; 95% confidence interval, 2.18-5.00) and surgical subspecialty (odds ratio, 2.45; 95% confidence interval, 1.57-3.82). About 20% of errors could have resulted in moderate to severe harm, for which significant independent predictors were found.

CONCLUSIONS

Despite standardization of data entry, inconsistent communication in CPOE poses a significant risk to safety. Improving the usability of the CPOE interface and integrating it with workflow may reduce this risk.

Health IT acceptance factors in long-term care facilities: a cross-sectional survey

BACKGROUND AND PURPOSE

This study applied a modified version of the extended technology acceptance model (TAM2) to examine the factors determining the acceptance of health IT applications by caregivers in long-term care facilities. The antecedent variables, including social influence factors such as subjective norm and image were examined together with demographic variables including age, job level, long-term care work experience and computer skills in regard to their impact on caregivers' acceptance of health IT applications.

METHODS

A self-administered questionnaire was developed based on the validated items from TAM2. The data was collected in a cross-sectional survey using convenience sample. Confirmatory factor analysis and structural equation modelling techniques were used to validate our causal model.

RESULTS

Perceived usefulness, perceived ease of use and computer skills had significant positive impact, whereas image had significant negative impact on caregivers' intention to use health IT applications. Image, subjective norm and computer skills also indirectly impacted on intention through the mediating factor of ease of use. Ease of use, subjective norm and job level also determined perceived usefulness. The other demographic factors (including age and long-term care work experience) did not have any significant effect on caregivers' acceptance of a health IT application. Our model explains 34% of caregivers' intention to use an introduced IT application before any hands-on experience with the system established.

CONCLUSIONS

The planners and managers should ensure that a health IT application to be introduced into a long-term care facility is useful and easy to use. Effort should be focused on forming a positive social norm for the introduction of the new innovation and improving caregivers' computer skills. Securing the managers' and senior nurses' support for the innovation at the onset of the project is critical for success. Finally the caregivers appear to dislike the idea of increased IT ability will elevate their status.

The impact of computerized prescribing on error rate in a department of Oncology/Hematology

AIMS

A comparison of prescribing errors detected for computerized and spreadsheet prescriptions in the Department of Hematology and Oncology of the Norfolk and Norwich University hospital.

METHODS

A prospective audit of 1941 prescriptions for chemotherapy was made from January to September 2005. Each new cycle of chemotherapy ordered was monitored for prescribing errors, which were analyzed by method of prescription (computerized or spreadsheet), prescriber, type, and severity.

RESULTS

Computerized prescribing reduced errors by 42% (RR 0.58; 95% CI 0.47-0.72). Errors occurred in 20% of spreadsheet prescriptions compared with 12% of the computerized prescriptions. There was a significant difference in error rates of three different prescribers whichever prescribing system was used. The proportion of errors that were minor was reduced and serious was increased with little change in the proportion of significant or life-threatening errors.

CONCLUSIONS

The impact of computerized prescribing on adverse drug events requires further evaluation. Prescriber training may be important in further reducing errors. The implementation of all the existing functions of the electronic system should lead to further reduction in errors.

A cluster randomized clinical trial to improve prescribing patterns in ambulatory pediatrics

OBJECTIVES

Having shown previously that an electronic prescription writer and decision support system improved pediatric prescribing behavior for otitis media in an academic clinic setting, we assessed whether point-of-care delivery of evidence could demonstrate similar effects for a wide range of other common pediatric conditions.

DESIGN

Cluster randomized controlled trial.

SETTING

A teaching clinic/clinical practice site and a primary care pediatric clinic serving a rural and semi-urban patient mix.

PARTICIPANTS

A total of 36 providers at the teaching clinic/practice site and eight providers at the private primary pediatric clinic.

INTERVENTION

An evidence-based message system that presented real-time evidence to providers based on prescribing practices for acute otitis media, allergic rhinitis, sinusitis, constipation, pharyngitis, croup, urticaria, and bronchiolitis.

OUTCOME MEASURES

The proportion of prescriptions dispensed in accordance with evidence.

RESULTS

The proportion of prescriptions dispensed in accordance with evidence improved four percentage points, from 38% at baseline to 42% following the intervention. The control group improved by one percentage point, from 39% at baseline to 40% at trial's conclusion. The adjusted difference between the intervention and control groups was 8% (95% confidence interval 1%, 15%). Intervention effectiveness did not decrease with time.

CONCLUSION

For common pediatric outpatient conditions, a point-of-care evidence-based prescription writer and decision support system was associated with significant improvements in prescribing practices.

A roadmap for national action on clinical decision support

This document comprises an AMIA Board of Directors approved White Paper that presents a roadmap for national action on clinical decision support. It is published in JAMIA for archival and dissemination purposes. The full text of this material has been previously published on the AMIA Web site (www.amia.org/inside/initiatives/cds). AMIA is the copyright holder.

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors

PURPOSE

In order to better understand physicians' perspectives about the use of clinical information technology (CIT) to reduce medical errors, we asked physicians about opportunities and issues around clinical use of computerized physician order entry (CPOE) systems, order sets within CPOE, and handheld computers (HHCs).

METHODS

We conducted 10 focus groups including 71 physicians involved in technology implementation efforts across the US between April 2002 and February 2005.

RESULTS

Two major themes emerged across focus groups around reliance on CIT to reduce errors: (1) can it work? and (2) at what cost to the medical profession? Within the first theme, physicians expressed concern about the appropriateness of physician-directed CIT as a solution for medical errors, concerns regarding the current technical capabilities and level of technical support for CIT solutions, and concern about the introduction of new errors. Within the second theme, physicians were particularly concerned about time efficiency and workload redistribution associated with the introduction of CIT. Across focus groups, physicians tended to generalize about the role of all IT in their lives, potentially biasing opinions about specific technologies.

CONCLUSIONS

Health care organizations attempting to promote physician use of CIT are advised to deepen consideration of physicians' perspectives about technology adoption and use in order to address their concerns, reduce skepticism, and increase the likelihood of implementation success.

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

BACKGROUND

The transfer of care for hospitalized patients between inpatient physicians is routinely mediated through written and verbal communication or "sign-out". This study aims to describe how communication failures during this process can lead to patient harm.

METHODS

In interviews employing critical incident technique, first year resident physicians (interns) described (1) any adverse events or near misses due to suboptimal preceding patient sign-out; (2) the worst event due to suboptimal sign-out in which they were involved; and (3) suggestions to improve sign-out. All data were analyzed and categorized using the constant comparative method with independent review by three researchers.

RESULTS

Twenty six interns caring for 82 patients were interviewed after receiving sign-out from another intern. Twenty five discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Inter-rater agreement for categorization was high (kappa 0.78-1.00). Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. In nearly all cases these failures led to uncertainty during decisions on patient care. Uncertainty may result in inefficient or suboptimal care such as repeat or unnecessary tests. Interns desired thorough but relevant face-to-face verbal sign-outs that reviewed anticipated issues. They preferred legible, accurate, updated, written sign-out sheets that included standard patient content such as code status or active and anticipated medical problems.

CONCLUSION

Communication failures during sign-out often lead to uncertainty in decisions on patient care. These may result in inefficient or suboptimal care leading to patient harm.

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

BACKGROUND

The transfer of care for hospitalized patients between inpatient physicians is routinely mediated through written and verbal communication or "sign-out". This study aims to describe how communication failures during this process can lead to patient harm.

METHODS

In interviews employing critical incident technique, first year resident physicians (interns) described (1) any adverse events or near misses due to suboptimal preceding patient sign-out; (2) the worst event due to suboptimal sign-out in which they were involved; and (3) suggestions to improve sign-out. All data were analyzed and categorized using the constant comparative method with independent review by three researchers.

RESULTS

Twenty six interns caring for 82 patients were interviewed after receiving sign-out from another intern. Twenty five discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Inter-rater agreement for categorization was high (kappa 0.78-1.00). Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. In nearly all cases these failures led to uncertainty during decisions on patient care. Uncertainty may result in inefficient or suboptimal care such as repeat or unnecessary tests. Interns desired thorough but relevant face-to-face verbal sign-outs that reviewed anticipated issues. They preferred legible, accurate, updated, written sign-out sheets that included standard patient content such as code status or active and anticipated medical problems.

CONCLUSION

Communication failures during sign-out often lead to uncertainty in decisions on patient care. These may result in inefficient or suboptimal care leading to patient harm.

Adding insight: a qualitative cross-site study of physician order entry

The research questions, strategies, and results of a 7-year qualitative study of computerized physician order entry implementation (CPOE) at successful sites are reviewed over time. The iterative nature of qualitative inquiry stimulates a consecutive stream of research foci, which, with each iteration, add further insight into the overarching research question. A multidisciplinary team of researchers studied CPOE implementation in four organizations using a multi-method approach to address the question "what are the success factors for implementing CPOE?" Four major themes emerged after studying three sites; ten themes resulted from blending the first results with those from a fourth site; and twelve principles were generated when results of a qualitative analysis of consensus conference transcripts were combined with the field data. The study has produced detailed descriptions of factors related to CPOE success and insight into the implementation process.

Health information technology and physician-patient interactions: impact of computers on communication during outpatient primary care visits

OBJECTIVE

The aim of this study was to evaluate the impact of introducing health information technology (HIT) on physician-patient interactions during outpatient visits.

DESIGN

This was a longitudinal pre-post study: two months before and one and seven months after introduction of examination room computers. Patient questionnaires (n = 313) after primary care visits with physicians (n = 8) within an integrated delivery system. There were three patient satisfaction domains: (1) satisfaction with visit components, (2) comprehension of the visit, and (3) perceptions of the physician's use of the computer.

RESULTS

Patients reported that physicians used computers in 82.3% of visits. Compared with baseline, overall patient satisfaction with visits increased seven months after the introduction of computers (odds ratio [OR] = 1.50; 95% confidence interval [CI]: 1.01-2.22), as did satisfaction with physicians' familiarity with patients (OR = 1.60, 95% CI: 1.01-2.52), communication about medical issues (OR = 1.61; 95% CI: 1.05-2.47), and comprehension of decisions made during the visit (OR = 1.63; 95% CI: 1.06-2.50). In contrast, there were no significant changes in patient satisfaction with comprehension of self-care responsibilities, communication about psychosocial issues, or available visit time. Seven months post-introduction, patients were more likely to report that the computer helped the visit run in a more timely manner (OR = 1.76; 95% CI: 1.28-2.42) compared with the first month after introduction. There were no other significant changes in patient perceptions of the computer use over time.

CONCLUSION

The examination room computers appeared to have positive effects on physician-patient interactions related to medical communication without significant negative effects on other areas such as time available for patient concerns. Further study is needed to better understand HIT use during outpatient visits.

Computerized physician order entry in the critical care and general inpatient setting: a narrative review

Computerized physician order entry (CPOE) is an increasingly used technologic tool for entering clinician orders, especially for medications and laboratory and diagnostic tests. Studies in hospitalized patients, including critically ill patients, have demonstrated that CPOE, especially with decision support, improves several outcomes. These improved outcomes include clinical measures such as reductions in serious medication errors and enhanced antimicrobial management of critically ill patients resulting in reduced length of stay. Additionally, several process outcomes have improved with CPOE such as increased compliance with evidence-based practices, reductions in unnecessary laboratory tests and cost savings in pharmacotherapeutics. Future studies are needed to demonstrate the benefits of more patient specific decision support interventions and the seamless integration of CPOE into a wireless, computerized medication administration system.

Information retrieval performance of probabilistically generated, problem-specific computerized provider order entry pick-lists: a pilot study

OBJECTIVE

The aim of this study was to preliminarily determine the feasibility of probabilistically generating problem-specific computerized provider order entry (CPOE) pick-lists from a database of explicitly linked orders and problems from actual clinical cases.

DESIGN

In a pilot retrospective validation, physicians reviewed internal medicine cases consisting of the admission history and physical examination and orders placed using CPOE during the first 24 hours after admission. They created coded problem lists and linked orders from individual cases to the problem for which they were most indicated. Problem-specific order pick-lists were generated by including a given order in a pick-list if the probability of linkage of order and problem (PLOP) equaled or exceeded a specified threshold. PLOP for a given linked order-problem pair was computed as its prevalence among the other cases in the experiment with the given problem. The orders that the reviewer linked to a given problem instance served as the reference standard to evaluate its system-generated pick-list.

MEASUREMENTS

Recall, precision, and length of the pick-lists.

RESULTS

Average recall reached a maximum of .67 with a precision of .17 and pick-list length of 31.22 at a PLOP threshold of 0. Average precision reached a maximum of .73 with a recall of .09 and pick-list length of .42 at a PLOP threshold of .9. Recall varied inversely with precision in classic information retrieval behavior.

CONCLUSION

We preliminarily conclude that it is feasible to generate problem-specific CPOE pick-lists probabilistically from a database of explicitly linked orders and problems. Further research is necessary to determine the usefulness of this approach in real-world settings.

How disease surveillance systems can serve as practical building blocks for a health information infrastructure: the Indiana experience

Although many organizations are beginning to develop strategies to implement and study regional and national health information exchanges, there are few operational examples to date. The Indiana Network for Patient Care (INPC) is an example of a currently operational Regional Health Information Organization (RHIO) built upon a foundation of open, robust healthcare information standards. Having demonstrated the scalability of this design, the Indiana State Department of Health (ISDH) contracted with the Regenstrief Institute to implement a statewide disease surveillance system incorporating encounter data from all 114 Indiana hospitals with emergency departments. We describe the 4-year implementation plan, including our design rationale and how we plan to address the specific implementation challenges of data collection, connectivity in diverse environments and current hospital buy-in. To date, 36 hospitals are in various stages of engagement, with 19 hospitals actively providing real-time surveillance data. We will discuss how this project creates the foundation for a potential statewide health information exchange.

Information resources used in antimicrobial prescribing

To describe resources clinicians use when they prescribe antimicrobials, the authors surveyed prescribers by telephone within hours (median 2.9) after they ordered one or more antimicrobials for a patient. Among 157 prescribers, 87 (55%) used one or more external resources to aid in decisions about their order. The other 70 (45%) used only their own knowledge and experience. Fifty-nine (38%) consulted another person. Fifty-four (34%) used a print, computer, or Internet resource. In multivariate analysis, use of an external resource was associated with the clinician being on the medical service (odds ratio [OR] 2.99, 95% confidence interval [CI] 1.41-6.3) or being an intern (OR 13.65, 95% CI 1.44-128). Eighty percent of providers said information about antimicrobial prescribing at the point of electronic order entry would be helpful. It was concluded that decision support at the point of electronic order entry is likely to be used and might improve antimicrobial prescribing.