Health Information Technology Coordination to Support Patient-centered Care Coordination

OBJECTIVE

To select papers published in 2014, illustrating how information technology can contribute to and improve patient-centered care coordination.

METHOD

The two section editors performed a literature review from Medline and Web of Science to select a list of candidate best papers on the use of information technology for patient-centered care coordination. These papers were peer-reviewed by external reviewers and three of them were selected as "best papers".

RESULTS

The first selected paper reports a qualitative study exploring the gap between current practices of care coordination in various settings and idealized longitudinal care plans. The second selected paper illustrates several unintended consequences of HIT designed to improve care coordination. The third selected paper shows that advanced analytic techniques in medical informatics can be instrumental in studying patient-centered care coordination.

CONCLUSIONS

The realization of true patient-centered care coordination is dependent upon a number of factors. Standardization of clinical documentation and HIT interoperability across organization and settings is a critical prerequisite for HIT to support patient-centered care coordination. Enabling patient involvement is an efficient means for goal setting and health information sharing. Additionally, unintended consequences of HIT tools (both positive and negative) must be measured and taken into account for quality improvement.

A prognostic model based on readily available clinical data enriched a pre-emptive pharmacogenetic testing program

OBJECTIVES

We describe the development, implementation, and evaluation of a model to pre-emptively select patients for genotyping based on medication exposure risk.

STUDY DESIGN AND SETTING

Using deidentified electronic health records, we derived a prognostic model for the prescription of statins, warfarin, or clopidogrel. The model was implemented into a clinical decision support (CDS) tool to recommend pre-emptive genotyping for patients exceeding a prescription risk threshold. We evaluated the rule on an independent validation cohort and on an implementation cohort, representing the population in which the CDS tool was deployed.

RESULTS

The model exhibited moderate discrimination with area under the receiver operator characteristic curves ranging from 0.68 to 0.75 at 1 and 2 years after index dates. Risk estimates tended to underestimate true risk. The cumulative incidences of medication prescriptions at 1 and 2 years were 0.35 and 0.48, respectively, among 1,673 patients flagged by the model. The cumulative incidences in the same number of randomly sampled subjects were 0.12 and 0.19, and in patients over 50 years with the highest body mass indices, they were 0.22 and 0.34.

CONCLUSION

We demonstrate that prognostic algorithms can guide pre-emptive pharmacogenetic testing toward those likely to benefit from it.

Electronic health record design and implementation for pharmacogenomics: a local perspective

PURPOSE

The design of electronic health records to translate genomic medicine into clinical care is crucial to successful introduction of new genomic services, yet there are few published guides to implementation.

METHODS

The design, implemented features, and evolution of a locally developed electronic health record that supports a large pharmacogenomics program at a tertiary-care academic medical center was tracked over a 4-year development period.

RESULTS

Developers and program staff created electronic health record mechanisms for ordering a pharmacogenomics panel in advance of clinical need (preemptive genotyping) and in response to a specific drug indication. Genetic data from panel-based genotyping were sequestered from the electronic health record until drug-gene interactions met evidentiary standards and deemed clinically actionable. A service to translate genotype to predicted drug-response phenotype populated a summary of drug-gene interactions, triggered inpatient and outpatient clinical decision support, updated laboratory records, and created gene results within online personal health records.

CONCLUSION

The design of a locally developed electronic health record supporting pharmacogenomics has generalizable utility. The challenge of representing genomic data in a comprehensible and clinically actionable format is discussed along with reflection on the scalability of the model to larger sets of genomic data.

Optimizing drug outcomes through pharmacogenetics: a case for preemptive genotyping

Routine integration of genotype data into drug decision making could improve patient safety, particularly if many relevant genetic variants can be assayed simultaneously before prescribing the target drug. The frequency of opportunities for pharmacogenetic prescribing and the potential adverse events (AEs) mitigated are unknown. We examined the frequency with which 56 medications with known outcomes influenced by variant alleles were prescribed in a cohort of 52,942 medical home patients at Vanderbilt University Medical Center (VUMC). Within a 5-year window, we estimated that 64.8% (95% confidence interval (CI): 64.4-65.2%) of individuals were exposed to at least one medication with an established pharmacogenetic association. Using previously published results for six medications with severe, well-characterized, genetically linked AEs, we estimated that 383 events (95% CI, 212-552) could have been prevented with an effective preemptive genotyping program. Our results suggest that multiplexed, preemptive genotyping may represent an efficient alternative approach to current single-use ("reactive") methods and may also improve safety.

Identifying asthma exacerbations in a pediatric emergency department: a feasibility study

BACKGROUND

Asthma is a common pediatric chronic disease and is estimated to account for more than 2million emergency department visits per year. Asthma guidelines have demonstrated improved outcomes, but remain underutilized due to several barriers. Computerized methods to automatically identify asthma exacerbations may be beneficial to initiate guideline recommended treatment, but have not been described. The goal of the study was to examine the accuracy of an algorithm to identify asthma patients at triage in real-time using only electronically available data.

METHODS

During a 9-month period, the five most frequent presenting chief complaints for Emergency Department asthma patients aged 2-18 years were identified and accounted for >95% of asthma visits: wheezing, shortness of breath, fever, cough, and dyspnea. During a following 1-month period (November 2004), medical records of all patients with one of the five chief complaints were reviewed to establish a reference standard diagnosis. An asthma identification algorithm was developed that considered only data available in electronic format at the time of triage and included the presenting chief complaint, information from the computerized problem list (past medical history; current medications, such as beta-agonists, steroids, and other asthma medications), and ICD-9 billing codes from previous encounters.

RESULTS

From 1835 Emergency Department visits, 368 visits (154 with asthma) had one of the five chief complaints and were included. A problem list was available in 203 (55.2%) and an ICD-9 code in 68 (18.5%) patients. Wheezing accounted for 56.5% of asthma visits, while fever was the most frequent chief complaint among all patients (43.8%). The asthma identification algorithm had a sensitivity of 44.8% (95% CI: 36.8-53.0%), a specificity of 91.6% (CI: 87.0-94.9%), a positive predictive value of 79.3% (CI: 69.3-87.3%) and a negative predictive value of 69.8% (CI: 64.0-75.1%). The positive and negative likelihood ratios were 5.3 (CI: 3.3-8.6) and 0.6 (CI: 0.5-0.7), respectively.

CONCLUSION

The simple identification algorithm demonstrated good accuracy for identifying asthma episodes. The algorithm may represent a promising and feasible approach to create computerized reminders or automatic triggers that can facilitate the initiation of guideline-based asthma treatment in the Emergency Department.

Prospective evaluation of a closed-loop, computerized reminder system for pneumococcal vaccination in the emergency department

The Emergency Department is a suitable but challenging environment to implement a sustainable pneumococcal vaccination program. To increase vaccination rates for patients > or equal to 65 years old, we prospectively evaluated a closed-loop informatics approach over a 6-week study period. Among the 572 candidate patients, 284 were up-to-date with vaccination, 187 patients refused vaccination, 65 physicians declined to order the vaccine, and 28 patients received the vaccine during the ED visit. The informatics approach increased vaccination rate from a baseline of 49.8% to 54.9% (p < 0.01).

Creating and validating a pneumococcal vaccination registry

Healthy People 2010 set a goal of 90% vaccination rate for pneumococcal vaccine in elderly patients. We developed a keyword search, using pharmacy orders for Pneumovax as a gold standard, to determine patient eligibility for a computerized pneumococcal vaccination registry. The keyword search captured 98% of vaccinations in the validation dataset. A total of 4,768 patients matched at least one keyword in the search and were added to the immunization registry. Through our search, we found a 63% vaccination rate in the primary care patient population older than 65, leaving 37% of the high risk population still needing vaccinations.

StarTracker: an integrated, web-based clinical search engine

This poster details the design and use of the StarTracker clinical search engine. This program is fully integrated within our electronic medical record system and allows users to enter simple rules that direct formatted searches of multiple legacy databases.

Initializing the VA medication reference terminology using UMLS metathesaurus co-occurrences

We developed and evaluated a UMLS Metathesaurus Co-occurrence mining algorithm to connect medications and diseases they may treat. Based on 16 years of co-occurrence data, we created 977 candidate drug-disease pairs for a sample of 100 ingredients (50 commonly prescribed and 50 selected at random). Our evaluation showed that more than 80% of the candidate drug-disease pairs were rated "APPROPRIATE" by physician raters. Additionally, there was a highly significant correlation between the overall frequency of citation and the likelihood that the connection was rated "APPROPRIATE." The drug-disease pairs were used to initialize term definitions in an ongoing effort to build a medication reference terminology for the Veterans Health Administration. Co-occurrence mining is a valuable technique for initializing term definitions in a large-scale reference terminology creation project.

Elder abuse in people with dementia in Northern Ireland: Prevalence and predictors in cases referred to a psychiatry of old age service

OBJECTIVE

To establish the prevalence of elder abuse in community-dwelling patients with dementia and to test the hypothesis that there is no difference in carer and patient characteristics between the abused and non-abused populations.

DESIGN

A cohort of consecutive referrals was formed and subdivided by the presence or absence of abuse and the two groups compared.

SETTING

A rural psychiatry of old age service in N. Ireland.

SUBJECTS

Each case had been newly referred, was 65 years old or over, lived at home, had an identifiable carer and met DSMIII-R criteria for a diagnosis of dementia. There were 49 such cases; 38 carers agreed to be interviewed.

MAIN OUTCOME MEASURES

The General Health Questionnaire 28, the Gilleard Pre-Morbid Relationship Rating Scale and Gilleard's Problem Checklist were administered to the carer and the information/orientation sub scale of the Clifton Assessment Procedure for the Elderly used to measure cognitive impairment in the patient.

RESULTS

Abuse was elicited in 14 (37%) cases; four (10.5%) of physical and 13 (34%) of verbal abuse. No cases of abuse by neglect were detected. A poor premorbid relationship, verbal or physical abuse by the dependant, problem behaviours in the dependant, the carer's level of anxiety and a perception of not receiving help were significantly associated with abuse. Alcohol consumption of the carer, physical dependence, severity of cognitive impairment or financial or social circumstances were not associated with elder abuse.

CONCLUSIONS

Elder abuse is associated with aspects of the patient/carer relationship and should be regarded as a significant problem in patients with dementia referred to an old age service.

Psychological consequences of the Kegworth air disaster

BACKGROUND

The study sought to quantify psychiatric morbidity among survivors of a major air crash and to identify aetiological factors linked with post-traumatic stress disorder (PTSD).

METHOD

Sixty-eight of the 79 survivors (86%) were assessed at a clinical interview within one year of the disaster. The majority also completed the General Health Questionnaire, the Impact of Events Scale (IES) and the Zung Anxiety and Depression Scales.

RESULTS

Fifty-four of the study group (79%) met DSM-III-R criteria for a psychiatric disorder within one year of the disaster, of whom 27 (50%) had PTSD. Those who saw injured or dead people at the scene, or had sustained less severe injuries as measured by their Injury Severity Scores, or were under 35 years old, were significantly more likely to develop PTSD.

CONCLUSIONS

High rates of psychiatric morbidity are found in survivors of transportation disasters. Further studies are needed to identify those at most risk and to evaluate the benefits of psychological intervention.

Worksite follow-up and engagement strategies for initiating health risk behavior changes

Information is presented from a multiplant study of interventions to improve cardiovascular health among employees. Risk factors targeted were high blood pressure, obesity, and cigarette smoking. The study utilized on-site wellness counselors who periodically contacted all employees identified through screening as having one or more of the three risks. Use of a structured protocol for client outreach resulted in the large majority of clients being seen in follow-up during the three-year intervention period. Drawing from caseload experience and from various theoretical perspectives, seven engagement strategies were used to help guide at-risk clients toward successful behavior changes to reduce health risks. Results showed that of the three at-risk groups, clients with high blood pressure were most likely to be seen in follow-up, and most likely to begin a risk reduction program. For the overweight and smokers, clients seen three or more times were more likely to begin a weight-loss/smoking cessation program than clients seen less often. Frequency of follow-up showed a positive relationship with risk reduction for all three risks, in samples of employees rescreened at the end of the intervention period, but the relationship was not statistically significant for smoking cessation.