Provider use of and attitudes towards an active clinical alert: a case study in decision support

A Cross-Sectional Study of the Characteristics Associated With Chronic Pain Documentation on the Problem List

ABSTRACT

Chronic pain is often elusive because of its specific diagnosis and complex presentation, making it challenging for healthcare providers to develop safe and effective treatment plans. Experts recommend a multifaceted approach to managing chronic pain that requires interdisciplinary communication and coordination. Studies have found that patients with a complete problem list receive better follow-up care. This study aimed to determine the factors associated with chronic pain documentation in the problem list. This study included 126 clinics and 12,803 patients 18 years or older with a chronic pain diagnosis within 6 months before or during the study period. The findings revealed that 46.4% of the participants were older than 60 years, 68.3% were female, and 52.1% had chronic pain documented on their problem list. Chi-square tests revealed significant differences in demographics between those who did and did not have chronic pain documented on their problem list, with 55.2% of individuals younger than 60 years having chronic pain documented on their problem list, 55.0% of female patients, 60.3% of Black non-Hispanic people, and 64.8% of migraine sufferers. Logistic regression analysis revealed that age, sex, race/ethnicity, diagnosis type, and opioid prescriptions were significant predictors of chronic pain documentation on the problem list.

Modulators Influencing Medication Alert Acceptance: An Explorative Review

OBJECTIVES

Clinical decision support systems (CDSSs) use alerts to enhance medication safety and reduce medication error rates. A major challenge of medication alerts is their low acceptance rate, limiting their potential benefit. A structured overview about modulators influencing alert acceptance is lacking. Therefore, we aimed to review and compile qualitative and quantitative modulators of alert acceptance and organize them in a comprehensive model.

METHODS

In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline, a literature search in PubMed was started in February 2018 and continued until October 2021. From all included articles, qualitative and quantitative parameters and their impact on alert acceptance were extracted. Related parameters were then grouped into factors, allocated to superordinate determinants, and subsequently further allocated into five categories that were already known to influence alert acceptance.

RESULTS

Out of 539 articles, 60 were included. A total of 391 single parameters were extracted (e.g., patients' comorbidity) and grouped into 75 factors (e.g., comorbidity), and 25 determinants (e.g., complexity) were consequently assigned to the predefined five categories, i.e., CDSS, care provider, patient, setting, and involved drug. More than half of all factors were qualitatively assessed (n = 21) or quantitatively inconclusive (n = 19). Furthermore, 33 quantitative factors clearly influenced alert acceptance (positive correlation: e.g., alert type, patients' comorbidity; negative correlation: e.g., number of alerts per care provider, moment of alert display in the workflow). Two factors (alert frequency, laboratory value) showed contradictory effects, meaning that acceptance was significantly influenced both positively and negatively by these factors, depending on the study. Interventional studies have been performed for only 12 factors while all other factors were evaluated descriptively.

CONCLUSION

This review compiles modulators of alert acceptance distinguished by being studied quantitatively or qualitatively and indicates their effect magnitude whenever possible. Additionally, it describes how further research should be designed to comprehensively quantify the effect of alert modulators.

Reducing Alert Burden in Electronic Health Records: State of the Art Recommendations from Four Health Systems

BACKGROUND

Electronic health record (EHR) alert fatigue, while widely recognized as a concern nationally, lacks a corresponding comprehensive mitigation plan.

OBJECTIVES

The goal of this manuscript is to provide practical guidance to clinical informaticists and other health care leaders who are considering creating a program to manage EHR alerts.

METHODS

This manuscript synthesizes several approaches and recommendations for better alert management derived from four U.S. health care institutions that presented their experiences and recommendations at the American Medical Informatics Association 2019 Clinical Informatics Conference in Atlanta, Georgia, United States. The assembled health care institution leaders represent academic, pediatric, community, and specialized care domains. We describe governance and management, structural concepts and components, and human-computer interactions with alerts, and make recommendations regarding these domains based on our experience supplemented with literature review. This paper focuses on alerts that impact bedside clinicians.

RESULTS

The manuscript addresses the range of considerations relevant to alert management including a summary of the background literature about alerts, alert governance, alert metrics, starting an alert management program, approaches to evaluating alerts prior to deployment, and optimization of existing alerts. The manuscript includes examples of alert optimization successes at two of the represented institutions. In addition, we review limitations on the ability to evaluate alerts in the current state and identify opportunities for further scholarship.

CONCLUSION

Ultimately, alert management programs must strive to meet common goals of improving patient care, while at the same time decreasing the alert burden on clinicians. In so doing, organizations have an opportunity to promote the wellness of patients, clinicians, and EHRs themselves.

Electronic problem lists: a thematic analysis of a systematic literature review to identify aspects critical to success

Objective

Problem list data is a driving force for many beneficial clinical tools, yet these data remain underutilized. We performed a systematic literature review, pulling insights from previous research, aggregating insights into themes, and distilling themes into actionable advice. We sought to learn what changes we could make to existing applications, to the clinical workflow, and to clinicians' perceptions that would improve problem list utilization and increase the prevalence of problems data in the electronic medical record.

Materials and Methods

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to systematically curate a corpus of pertinent articles. We performed a thematic analysis, looking for interesting excerpts and ideas. By aggregating excerpts from many authors, we gained broader, more inclusive insights into what makes a good problem list and what factors are conducive to its success.

Results

Analysis led to a list of 7 benefits of using the problem list, 15 aspects critical to problem list success, and knowledge to help inform policy development, such as consensus on what belongs on the problem list, who should maintain the problem list, and when.

Conclusions

A list of suggestions is made on ways in which the problem list can be improved to increase utilization by clinicians. There is also a need for standard measurements of the problem list, so that lists can be measured, compared, and discussed with rigor and a common vocabulary.

Evaluation of User-Interface Alert Displays for Clinical Decision Support Systems for Sepsis

BACKGROUND

Hospitals are increasingly turning to clinical decision support systems for sepsis, a life-threatening illness, to provide patient-specific assessments and recommendations to aid in evidence-based clinical decision-making. Lack of guidelines on how to present alerts has impeded optimization of alerts, specifically, effective ways to differentiate alerts while highlighting important pieces of information to create a universal standard for health care providers.

OBJECTIVE

To gain insight into clinical decision support systems-based alerts, specifically targeting nursing interventions for sepsis, with a focus on behaviors associated with and perceptions of alerts, as well as visual preferences.

METHODS

An interactive survey to display a novel user interface for clinical decision support systems for sepsis was developed and then administered to members of the nursing staff.

RESULTS

A total of 43 nurses participated in 2 interactive survey sessions. Participants preferred alerts that were based on an established treatment protocol, were presented in a pop-up format, and addressed the patient's clinical condition rather than regulatory guidelines.

CONCLUSIONS

The results can be used in future research to optimize electronic medical record alerting and clinical practice workflow to support the efficient, effective, and timely delivery of high-quality care to patients with sepsis. The research also may advance the knowledge base of what information health care providers want and need to improve the health and safety of their patients.

Primary Care Providers' Opening of Time-Sensitive Alerts Sent to Commercial Electronic Health Record InBaskets

BACKGROUND

Time-sensitive alerts are among the many types of clinical notifications delivered to physicians' secure InBaskets within commercial electronic health records (EHRs). A delayed alert review can impact patient safety and compromise care.

OBJECTIVE

To characterize factors associated with opening of non-interruptive time-sensitive alerts delivered into primary care provider (PCP) InBaskets.

DESIGN AND PARTICIPANTS

We analyzed data for 799 automated alerts. Alerts highlighted actionable medication concerns for older patients post-hospital discharge (2010-2011). These were study-generated alerts sent 3 days post-discharge to InBaskets for 75 PCPs across a multisite healthcare system, and represent a subset of all urgent InBasket notifications.

MAIN MEASURES

Using EHR access and audit logs to track alert opening, we performed bivariate and multivariate analyses calculating associations between patient characteristics, provider characteristics, contextual factors at the time of alert delivery (number of InBasket notifications, weekday), and alert opening within 24 h.

KEY RESULTS

At the time of alert delivery, the PCPs had a median of 69 InBasket notifications and had received a median of 379.8 notifications (IQR 295.0, 492.0) over the prior 7 days. Of the 799 alerts, 47.1% were opened within 24 h. Patients with longer hospital stays (>4 days) were marginally more likely to have alerts opened (OR 1.48 [95% CI 1.00-2.19]). Alerts delivered to PCPs whose InBaskets had a higher number of notifications at the time of alert delivery were significantly less likely to be opened within 24 h (top quartile >157 notifications: OR 0.34 [95% CI 0.18-0.61]; reference bottom quartile ≤42). Alerts delivered on Saturdays were also less likely to be opened within 24 h (OR 0.18 [CI 0.08-0.39]).

CONCLUSIONS

The number of total InBasket notifications and weekend delivery may impact the opening of time-sensitive EHR alerts. Further study is needed to support safe and effective approaches to care team management of InBasket notifications.

Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice

OBJECTIVE

This study assesses dental clinicians' pre- and post-implementation attitudes, skills, and experiences with three clinical decision support (CDS) tools built into the electronic health record (EHR) of a multi-specialty group dental practice.

METHODS

Electronic surveys designed to examine factors for acceptance of EHR-based CDS tools including caries management by risk assessment (CAMBRA), periodontal disease management by risk assessment (PEMBRA) and a risk assessment-based Proactive Dental Care Plan (PDCP) were distributed to all Willamette Dental Group employees at 2 time points; 3 months pre-implementation (Fall 2013) and 15 months after implementation (winter 2015). The surveys collected demographics, measures of job experience and satisfaction, and attitudes toward each CDS tool. The baseline survey response rate among clinicians was 83.1% (n = 567) and follow-up survey response rate was 63.2% (n = 508). Among the 344 clinicians who responded to both before and after surveys, 27% were general and specialist dentists, 32% were dental hygienists, and 41% were dental assistants.

RESULTS

Adherence to the CDS tools has been sustained at 98%+ since roll-out. Between baseline and follow-up, the change in mean attitude scores regarding CAMBRA reflect statistically significant improvement in formal training, knowing how to use the tools, belief in the science supporting the tools, and the usefulness of the tool to motivate patients. For PEMBRA, statistically significant improvement was found in formal training, knowing how to use the tools, belief in the science supporting the tools, with improvement also found in belief that the format and process worked well. Finally, for the PDCP, significant and positive changes were seen for every attitude and skill item scored. A strong and positive correlation with post-implementation attitudes was found with positive experiences in the work environment, whereas a negative correlation was found with workload and stress. Clinicians highly ranked a commitment to evidence-based care and sense that the tools were helping to improve patient care, health, and experience as motivations to use the tools. Peer pressure, fears about malpractice, and incentive pay were rated the lowest among the motivation factors.

CONCLUSION

This study shows that CDS tools built into the EHR can be successfully implemented in a dental practice and widely accepted by the entire clinical team. Achieving a high level of adherence to use of CDS can be done through adequate training, alignment with the mission and purpose of the organization, and is compatible with an improved work environment and clinician satisfaction.

Is the problem list in the eye of the beholder? An exploration of consistency across physicians

OBJECTIVE

Quantify the variability of patients' problem lists - in terms of the number, type, and ordering of problems - across multiple physicians and assess physicians' criteria for organizing and ranking diagnoses.

MATERIALS AND METHODS

In an experimental setting, 32 primary care physicians generated and ordered problem lists for three identical complex internal medicine cases expressed as detailed 2- to 4-page abstracts and subsequently expressed their criteria for ordering items in the list. We studied variability in problem list length. We modified a previously validated rank-based similarity measure, with range of zero to one, to quantify agreement between pairs of lists and calculate a single consensus problem list that maximizes agreement with each physician. Physicians' reasoning for the ordering of the problem lists was recorded.

RESULTS

Subjects' problem lists were highly variable. The median problem list length was 8 (range: 3-14) for Case A, 10 (range: 4-20) for Case B, and 7 (range: 3-13) for Case C. The median indices of agreement - taking into account the length, content, and order of lists - over all possible physician pairings was 0.479, 0.371, 0.509, for Cases A, B, and C, respectively. The median agreements between the physicians' lists and the consensus list for each case were 0.683, 0.581, and 0.697 (for Cases A, B, and C, respectively).Out of a possible 1488 pairings, 2 lists were identical. Physicians most frequently ranked problem list items based on their acuity and immediate threat to health.

CONCLUSIONS

The problem list is a physician's mental model of a patient's health status. These mental models were found to vary significantly between physicians, raising questions about whether problem lists created by individual physicians can serve their intended purpose to improve care coordination.

Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature

BACKGROUND

A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR). Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR.

METHODS

On both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements.

RESULTS

In this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability.

CONCLUSIONS

Two main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing the problem list or POMR.

Provider Attitudes Toward the Implementation of Clinical Decision Support Tools in Dental Practice

PURPOSE

The objective of this paper is to assess clinical dental providers' baseline knowledge and attitudes about the implementation of three clinical decision support (CDS) tools built into the electronic health record (EHR) of a multi-specialty group dental practice.

PROCEDURES

An electronic survey designed to examine predisposing factors for acceptance of EHR-based tools, caries and periodontal disease management by risk assessment and a risk assessment-based Proactive Dental Care Plan, was distributed to all Willamette Dental Group (WDG) employees. The survey collected demographic data, along with measures of job experience and satisfaction, comfort with dental information technology, and attitudes and knowledge of each CDS tool. WDG provided data on site-level patient and financing mix, patient satisfaction data, employee role (e.g. dentist) and tenure with company. The survey was conducted 3 months prior to the rollout of the CDS tools in November 2013. The survey was distributed electronically to all WDG employees (n = 1166), of whom 58.5% (n = 682) were clinicians, located in 53 sites in Oregon, Washington and Idaho. The overall response rate was 79.8% (n = 930), with a response rate of 83.1% (n = 567) from all clinicians. Of these, 24.3% were general and specialist dentists (n = 138); 26.6% were dental hygienists (n = 151), and 49% were dental assistants (n = 278).

PRINCIPAL FINDINGS

The clinicians surveyed reported being highly amenable to implementation of the three CDS tools. Clinicians' attitudes reflected higher expected improvement in patient care and quality than in business processes due to the implementation. The clinician characteristics most strongly correlated with a positive attitude toward the CDS tool implementation (as measured on Likert scale 1 = low to 5 = high) included satisfaction with the EHR (0.499, p < 0.001), job satisfaction (0.458, p < 0.001), finding change to be exciting (0.398, p < 0.001), degree of control perceived over work (0.352, p < 0.001), and a perception of having adequate tools to get work done (0.340, p < 0.001). Higher reported frequency (scale 1 = never, 7 = always) of feeling burned out (-0.297, p < 0.001), feeling emotionally drained (-0.265, p < 0.001), and feeling work is a strain (-0.205, p < 0.001) had the greatest correlation with negative attitudes.

CONCLUSION

This is the first study to examine dental provider attitudes toward the implementation of CDS tools incorporated within an electronic health record. Provider attitudes toward CDS tools can shape the entire implementation process for better or worse. This study contributes to the literature by providing an understanding of factors related to positive attitudes at the outset of a system change and can help guide organizational administrators to better prepare their workforce and organization for adoption of evidence-based dentistry tools such as a CDS system.

CSER and eMERGE: current and potential state of the display of genetic information in the electronic health record

OBJECTIVE

Clinicians' ability to use and interpret genetic information depends upon how those data are displayed in electronic health records (EHRs). There is a critical need to develop systems to effectively display genetic information in EHRs and augment clinical decision support (CDS).

MATERIALS AND METHODS

The National Institutes of Health (NIH)-sponsored Clinical Sequencing Exploratory Research and Electronic Medical Records & Genomics EHR Working Groups conducted a multiphase, iterative process involving working group discussions and 2 surveys in order to determine how genetic and genomic information are currently displayed in EHRs, envision optimal uses for different types of genetic or genomic information, and prioritize areas for EHR improvement.

RESULTS

There is substantial heterogeneity in how genetic information enters and is documented in EHR systems. Most institutions indicated that genetic information was displayed in multiple locations in their EHRs. Among surveyed institutions, genetic information enters the EHR through multiple laboratory sources and through clinician notes. For laboratory-based data, the source laboratory was the main determinant of the location of genetic information in the EHR. The highest priority recommendation was to address the need to implement CDS mechanisms and content for decision support for medically actionable genetic information.

CONCLUSION

Heterogeneity of genetic information flow and importance of source laboratory, rather than clinical content, as a determinant of information representation are major barriers to using genetic information optimally in patient care. Greater effort to develop interoperable systems to receive and consistently display genetic and/or genomic information and alert clinicians to genomic-dependent improvements to clinical care is recommended.

From bench to bed: bridging from informatics theory to practice. An exploratory analysis

BACKGROUND

In 2009, the journal Applied Clinical Informatics (ACI) commenced publication. Focused on applications in clinical informatics, ACI was intended to be a companion journal to METHODS of Information in Medicine (MIM). Both journals are official journals of IMIA, the International Medical Informatics Association.

OBJECTIVES

To explore, after five years, which congruencies and interdependencies exist in publications of these journals and to determine if gaps exist. To achieve this goal, major topics discussed in ACI and in MIM had to be analysed. Finally, we wanted to explore, whether the intention of publishing these companion journals to provide an information bridge from informatics theory to informatics practice and from practice to theory could be supported by this model. In this manuscript we will report on congruencies and interdependencies from practise to theory and on major topis in ACI. Further results will be reported in a second paper.

METHODS

Retrospective, prolective observational study on recent publications of ACI and MIM. All publications of the years 2012 and 2013 from these journals were indexed and analysed.

RESULTS

Hundred and ninety-six publications have been analysed (87 ACI, 109 MIM). In ACI publications addressed care coordination, shared decision support, and provider communication in its importance for complex patient care and safety and quality. Other major themes included improving clinical documentation quality and efficiency, effectiveness of clinical decision support and alerts, implementation of health information technology systems including discussion of failures and succeses. An emerging topic in the years analyzed was a focus on health information technology to predict and prevent hospital admissions and managing population health including the application of mobile health technology. Congruencies between journals could be found in themes, but with different focus in its contents. Interdependencies from practise to theory found in these publications, were only limited.

CONCLUSIONS

Bridging from informatics theory to practise and vice versa remains a major component of successful research and practise as well as a major challenge.