Guided medication dosing for elderly emergency patients using real-time, computerized decision support

OBJECTIVE

To evaluate the impact of a real-time computerized decision support tool in the emergency department that guides medication dosing for the elderly on physician ordering behavior and on adverse drug events (ADEs).

DESIGN

A prospective controlled trial was conducted over 26 weeks. The status of the decision support tool alternated OFF (7/17/06-8/29/06), ON (8/29/06-10/10/06), OFF (10/10/06-11/28/06), and ON (11/28/06-1/16/07) in consecutive blocks during the study period. In patients ≥65 who were ordered certain benzodiazepines, opiates, non-steroidals, or sedative-hypnotics, the computer application either adjusted the dosing or suggested a different medication. Physicians could accept or reject recommendations.

MEASUREMENTS

The primary outcome compared medication ordering consistent with recommendations during ON versus OFF periods. Secondary outcomes included the admission rate, emergency department length of stay for discharged patients, 10-fold dosing orders, use of a second drug to reverse the original medication, and rate of ADEs using previously validated explicit chart review.

RESULTS

2398 orders were placed for 1407 patients over 1548 visits. The majority (49/53; 92.5%) of recommendations for alternate medications were declined. More orders were consistent with dosing recommendations during ON (403/1283; 31.4%) than OFF (256/1115; 23%) periods (p≤0.0001). 673 (43%) visits were reviewed for ADEs. The rate of ADEs was lower during ON (8/237; 3.4%) compared with OFF (31/436; 7.1%) periods (p=0.02). The remaining secondary outcomes showed no difference.

LIMITATIONS

Single institution study, retrospective chart review for ADEs.

CONCLUSION

Though overall agreement with recommendations was low, real-time computerized decision support resulted in greater acceptance of medication recommendations. Fewer ADEs were observed when computerized decision support was active.

Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care

OBJECTIVE

Interruptive alerts within electronic applications can cause "alert fatigue" if they fire too frequently or are clinically reasonable only some of the time. We assessed the impact of non-interruptive, real-time medication laboratory alerts on provider lab test ordering.

DESIGN

We enrolled 22 outpatient practices into a prospective, randomized, controlled trial. Clinics either used the existing system or received on-screen recommendations for baseline laboratory tests when prescribing new medications. Since the warnings were non-interruptive, providers did not have to act upon or acknowledge the notification to complete a medication request.

MEASUREMENTS

Data were collected each time providers performed suggested laboratory testing within 14 days of a new prescription order. Findings were adjusted for patient and provider characteristics as well as patient clustering within clinics.

RESULTS

Among 12 clinics with 191 providers in the control group and 10 clinics with 175 providers in the intervention group, there were 3673 total events where baseline lab tests would have been advised: 1988 events in the control group and 1685 in the intervention group. In the control group, baseline labs were requested for 771 (39%) of the medications. In the intervention group, baseline labs were ordered by clinicians in 689 (41%) of the cases. Overall, no significant association existed between the intervention and the rate of ordering appropriate baseline laboratory tests.

CONCLUSION

We found that non-interruptive medication laboratory monitoring alerts were not effective in improving receipt of recommended baseline laboratory test monitoring for medications. Further work is necessary to optimize compliance with non-critical recommendations.

Non-interruptive drug-lab alerts in ambulatory care

To monitor potential adverse drug events, we devised a non-interruptive alert within our electronic medical record that prompted outpatient providers to order labs along with new prescriptions. When comparing control to intervention occurrences, we found the intervention had a non-significant impact on lab prescribing. The results of our prospective, randomized, controlled trial suggest that non-interruptive alerts are ineffective.

Electronic health records in specialty care: a time-motion study

BACKGROUND

Electronic health records (EHRs) have great potential to improve safety, quality, and efficiency in medicine. However, adoption has been slow, and a key concern has been that clinicians will require more time to complete their work using EHRs. Most previous studies addressing this issue have been done in primary care.

OBJECTIVE

To assess the impact of using an EHR on specialists' time. DESIGN Prospective, before-after trial of the impact of an EHR on attending physician time in four specialty clinics at an integrated delivery system: cardiology, dermatology, endocrine, and pain.

MEASUREMENTS

We used a time-motion method to measure physician time spent in one of 85 designated activities.

RESULTS

Attending physicians were monitored before and after the switch from paper records to a web-based ambulatory EHR. Across all specialties, 15 physicians were observed treating 157 patients while still using paper-based records, and 15 physicians were observed treating 146 patients after adoption. Following EHR implementation, the average adjusted total time spent per patient across all specialties increased slightly but not significantly (Delta = 0.94 min., p = 0.83) from 28.8 (SE = 3.6) to 29.8 (SE = 3.6) min.

CONCLUSION

These data suggest that implementation of an EHR had little effect on overall visit time in specialty clinics.

Correlates of electronic health record adoption in office practices: a statewide survey

OBJECTIVE

Despite emerging evidence that electronic health records (EHRs) can improve the efficiency and quality of medical care, most physicians in office practice in the United States do not currently use an EHR. We sought to measure the correlates of EHR adoption.

DESIGN

Mailed survey to a stratified random sample of all medical practices in Massachusetts in 2005, with one physician per practice randomly selected for survey.

MEASUREMENTS

EHR adoption rates.

RESULTS

The response rate was 71% (1345/1884). Overall, while 45% of physicians were using an EHR, EHRs were present in only 23% of practices. In multivariate analysis, practice size was strongly correlated with EHR adoption; 52% of practices with 7 or more physicians had an EHR, as compared with 14% of solo practices (adjusted odds ratio, 3.66; 95% confidence interval, 2.28-5.87). Hospital-based practices (adjusted odds ratio, 2.44; 95% confidence interval, 1.53-3.91) and practices that teach medical students or residents (adjusted odds ratio, 2.30; 95% confidence interval, 1.60-3.31) were more likely to have an EHR. The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%).

CONCLUSIONS

While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.

Stump appendicitis: a comprehensive review of literature

Appendectomy for appendicitis is one of the most common procedures performed in the United States. Residual tissue left after an initial appendectomy risks the development of stump appendicitis. A comprehensive review of the English-language literature revealed 36 reported cases of stump appendicitis. Typically, patients present with signs and symptoms similar to acute appendicitis; however, due to prior surgery, the diagnosis is difficult and the rate of appendiceal stump perforation is extremely high. Herein, we present a case of a 32-year-old female presenting with right lower quadrant pain, nausea, and fever 5 months after laparoscopic appendectomy. Upon surgery, an appendiceal stump was discovered.

Stump Appendicitis: A Comprehensive Review of Literature

Appendectomy for appendicitis is one of the most common procedures performed in the United States. Residual tissue left after an initial appendectomy risks the development of stump appendicitis. A comprehensive review of the English-language literature revealed 36 reported cases of stump appendicitis. Typically, patients present with signs and symptoms similar to acute appendicitis; however, due to prior surgery, the diagnosis is difficult and the rate of appendiceal stump perforation is extremely high. Herein, we present a case of a 32-year-old female presenting with right lower quadrant pain, nausea, and fever 5 months after laparoscopic appendectomy. Upon surgery, an appendiceal stump was discovered.

Concepts for building inter-organizational systems in healthcare: lessons from other industries

A centerpiece of the nation's healthcare information technology vision is the implementation of health information exchanges (HIEs). HIEs have the significant potential to improve the quality of patient care, reduce care costs, and enhance patient safety. These kinds of exchanges are new to healthcare in the United States. While more than 200 communities are in various stages of implementing them, there is little mature experience with the factors that contribute to the successful formation and sustainability of these exchanges. The creation and management of mechanisms to support the exchange of data between organizations has been used in other industries. There are many examples of interorganizational systems that have been established in industries as diverse as banking, manufacturing, government, and retail. This paper examines some of these experiences and attempts to glean the concepts and guidance healthcare can learn from other industries.

Modified herpes simplex virus delivery of enhanced GFP into the central nervous system

Controlled expression of proteins is a key experimental approach to a deeper understanding of the molecular basis of neuronal function. Here we evaluate the HSV-1 (herpes simplex virus) amplicon vector for gene delivery into the brains of living rats. We demonstrate that HSV-1 amplicon vectors expressing enhanced green fluorescent protein (EGFP) can reliably infect neurons after it is injected into cortex, striatum and thalamus in rats, producing sufficient numbers of infected neurons for electrophysiological experiments in acute brain slices. Expression of EGFP delivered by the HSV-1 amplicon was detected for up to 5 weeks post-infection. We detected no changes in the morphology or the electrophysiological properties of thalamic, striatal or cortical neurons within a period of at least 2 weeks after HSV-1 amplicon injection. We conclude that the HSV-1 amplicon is a valuable tool for gene delivery in the rat central nervous system.

Acute renal colic: value of unenhanced spiral computed tomography compared with intravenous urography

OBJECTIVE

The objective of this study was to compare the efficacy of plain spiral computed tomographic (CT) scan with intravenous urography (IVU) in the evaluation of patients with suspected urinary calculi/obstruction.

MATERIALS AND METHODS

Twenty consecutive patients with acute signs of renal colic were prospectively examined with unenhanced spiral CT followed by an IVU within the same day. The CT scans were reviewed jointly by 2 radiologists blinded to the IVU and a consensus was reached for each finding. The IVU was similarly reviewed by another 2 separate radiologists.

RESULTS

Eleven of the 20 patients had signs of urinary obstruction on CT and IVU. Of these 11 patients, 7 had a ureteric calculus that was demonstrated on CT and IVU and 4 had a calculus that was demonstrated on CT only. Two patients had a urinary calculus seen on CT and IVU with no signs of urinary obstruction. One patient had a calculus seen on CT alone with no urinary obstruction. Two patients only had signs of urinary obstruction on CT. The remaining 4 cases had normal findings on CT and IVU.

CONCLUSION

Unenhanced CT is more effective than IVU in identifying ureteric calculi and is equally effective in detecting urinary obstruction. CT is also useful in detecting secondary signs of obstruction even in the absence of any calculus.