Accuracy of a computerized clinical decision-support system for asthma assessment and management

Objective

To evaluate the accuracy of a computerized clinical decision-support system (CDSS) designed to support assessment and management of pediatric asthma in a subspecialty clinic.

Design

Cohort study of all asthma visits to pediatric pulmonology from January to December, 2009.

Measurements

CDSS and physician assessments of asthma severity, control, and treatment step.

Results

Both the clinician and the computerized CDSS generated assessments of asthma control in 767/1032 (74.3%) return patients, assessments of asthma severity in 100/167 (59.9%) new patients, and recommendations for treatment step in 66/167 (39.5%) new patients. Clinicians agreed with the CDSS in 543/767 (70.8%) of control assessments, 37/100 (37%) of severity assessments, and 19/66 (29%) of step recommendations. External review classified 72% of control disagreements (21% of all control assessments), 56% of severity disagreements (37% of all severity assessments), and 76% of step disagreements (54% of all step recommendations) as CDSS errors. The remaining disagreements resulted from pulmonologist error or ambiguous guidelines. Many CDSS flaws, such as attributing all ‘cough’ to asthma, were easily remediable. Pediatric pulmonologists failed to follow guidelines in 8% of return visits and 18% of new visits.

Limitations

The authors relied on chart notes to determine clinical reasoning. Physicians may have changed their assessments after seeing CDSS recommendations.

Conclusions

A computerized CDSS performed relatively accurately compared to clinicians for assessment of asthma control but was inaccurate for treatment. Pediatric pulmonologists failed to follow guideline-based care in a small proportion of patients.     

A framework for assessing patient crossover and health information exchange value

Objective

To evaluate the benefit of a health information exchange (HIE) between hospitals, we examine the rate of crossover among neurosurgical inpatients treated at Emory University Hospital (EUH) and Grady Memorial Hospital (GMH) in Atlanta, Georgia. To inform decisions regarding investment in HIE, we develop a methodology analyzing crossover behavior for application to larger more general patient populations.

Design

Using neurosurgery inpatient visit data from EUH and GMH, unique patients who visited both hospitals were identified through classification by name and age at time of visit. The frequency of flow patterns, including time between visits, and the statistical significance of crossover rates for patients with particular diagnoses were determined.

Measurements

The time between visits, flow patterns, and proportion of patients exhibiting crossover behavior were calculated for the total population studied as well as subpopulations.

Results

5.25% of patients having multiple visits over the study period visited the neurosurgical departments at both hospitals. 77% of crossover patients visited the level 1 trauma center (GMH) before visiting EUH.

Limitations

The true patient crossover may be under-estimated because the study population only consists of neurosurgical inpatients at EUH and GMH.

Conclusion

We demonstrate that detailed analysis of crossover behavior provides a deeper understanding of the potential value of HIE.     

Point-of-care clinical documentation: assessment of a bladder cancer informatics tool (eCancerCareBladder): a randomized controlled study of efficacy,efficiency and user friendliness compared with standard electronic medical records

Objective

To compare the use of structured reporting software and the standard electronic medical records (EMR) in the management of patients with bladder cancer. The use of a human factors laboratory to study management of disease using simulated clinical scenarios was also assessed.

Design

eCancerCare^Bladder and the EMR were used to retrieve data and produce clinical reports. Twelve participants (four attending staff, four fellows, and four residents) used either eCancerCare^Bladder or the EMR in two clinical scenarios simulating cystoscopy surveillance visits for bladder cancer follow-up.

Measurements

Time to retrieve and quality of review of the patient history; time to produce and completeness of a cystoscopy report. Finally, participants provided a global assessment of their computer literacy, familiarity with the two systems, and system preference.

Results

eCancerCare^Bladder was faster for data retrieval (scenario 1: 146 s vs 245 s, p=0.019; scenario 2: 306 vs 415 s, NS), but non-significantly slower to generate a clinical report. The quality of the report was better in the eCancerCare^Bladder system (scenario 1: p<0.001; scenario 2: p=0.11). User satisfaction was higher with the eCancerCare^Bladder system, and 11/12 participants preferred to use this system.

Limitations

The small sample size affected the power of our study to detect differences.

Conclusions

Use of a specific data management tool does not appear to significantly reduce user time, but the results suggest improvement in the level of care and documentation and preference by users. Also, the use of simulated scenarios in a laboratory setting appears to be a valid method for comparing the usability of clinical software.     

Variation of semen parameters in healthy medical students due to exam stress

Aim

This study was aimed at investigating semen parameters that vary most in samples of healthy donors undergoing stressful examination period.

Methods

Samples were left to liquefy in an incubator at 37°C, 5% CO2 for 30 minutes before volume was measured. Concentration and motility parameters were measured by means of computer assisted semen analysis (CASA) using Sperm Class Analyzer® (Microptic S.L, Madrid, Spain).

Results

Sperm concentration was significantly decreased in samples donated close to the exam period as well as samples donated during the exam period when compared to samples donated at the beginning of the semester.

Conclusion

Stress levels of donors might prove to be clinically relevant and important when designing experiment protocols.     

The impact of the electronic medical record on structure,process, and outcomes within primary care: a systematic review of the evidence

Background

The electronic medical record (EMR)/electronic health record (EHR) is becoming an integral component of many primary-care outpatient practices. Before implementing an EMR/EHR system, primary-care practices should have an understanding of the potential benefits and limitations.

Objective

The objective of this study was to systematically review the recent literature around the impact of the EMR/EHR within primary-care outpatient practices.

Materials and methods

Searches of Medline, EMBASE, CINAHL, ABI Inform, and Cochrane Library were conducted to identify articles published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. 30 studies met inclusion criteria.

Results and discussion

The EMR/EHR appears to have structural and process benefits, but the impact on clinical outcomes is less clear. Using Donabedian''s framework, five articles focused on the impact on healthcare structure, 21 explored healthcare process issues, and four focused on health-related outcomes.     

Development and Implementation of a Clinician Reporting System for Advanced Stage Cancer: Initial Lessons Learned

Objective

Innovative approaches can strengthen patient-caregiver-clinician information exchange and more effectively address the physical and psychosocial challenges of advanced disease. This study reports initial findings from implementation of the Clinician Report (CR)—a patient and caregiver status report tool accessible by the oncology clinic team.

Design

The CR tracks and communicates essential information from cancer patients and caregivers to the oncology team. The CR conveys patient symptoms, emotional strain, and key concerns.

Measurements

Authors used a model developed to explain acceptance, implementation, and sustainability of Interactive Health Communication Systems (IHCS) to evaluate implementation of the new CR system. The study carried out qualitative analyses of interviews with clinicians regarding their experience utilizing the Clinician Report.

Results

Primary CR benefits included enhancement of patients'' clinic visit experiences, greater caregiver involvement, and facilitation of earlier interventions. Challenges included CR functional issues, users'' desire for greater depth of information, user privacy concerns, and limited patient use. These findings are discussed using parameters of the implementation model. Limitations of this study include its small clinician sample size, which represented only a portion of existing organizational settings in which CR systems might be implemented.

Conclusion

Though in its early implementation stages, the CR demonstrates the potential to positively impact care delivery in the cancer clinic setting, particularly by facilitating earlier interventions and improving patient-caregiver-clinician communication both during and between clinic visits.     

Use of health information technology in home health and hospice agencies: United States, 2007

Objective

This report provides updated estimates on use of electronic medical records (EMRs) in US home health and hospice (HHH) agencies, describes utilization of EMR functionalities, and presents novel data on telemedicine and point of care documentation (PoCD) in this setting.

Design

Nationally representative, cross-sectional survey of US HHH agencies conducted in 2007.

Measurements

Data on agency characteristics, current use of EMR systems as well as use of telemedicine and PoCD were collected.

Results

In 2007, 43% of US HHH agencies reported use of an EMR system. Patient demographics (40%) and clinical notes (34%) were the most commonly used EMR functions among US HHH agencies. Only 20% of agencies with EMR systems had health information sharing functionality and about half of them used it. Telemedicine was used by 21% of all HHH agencies, with most (87%) of these offering home health services. Among home health agencies using telemedicine, greater than 90% used telephone monitoring and about two-thirds used non-video monitoring. Nearly 29% of HHH agencies reported using electronic PoCD systems, most often for Outcome and Assessment Information Set (OASIS) data capture (79%). Relative to for-profit HHH agencies, non-profit agencies used considerably more EMR (70% vs 28%, p<0.001) and PoCD (63% vs 9%, p<0.001).

Conclusions

Between 2000 and 2007, there was a 33% increase in use of EMR among HHH agencies in the US. In 2007, use of EMR and PoCD technologies in non-profit agencies was significantly higher than for-profit ones. Finally, HHH agencies generally tended to use available EMR functionalities, including health information sharing.     

Explaining physicians' use of EMR systems and performance in the shakedown phase

Objective

This work seeks to complement and extend prior work by using a multidisciplinary approach to explain electronic medical records (EMR) system use and consequent performance (here, patient satisfaction) among physicians during early stages of the implementation of an EMR.

Design

This was a quantitative study, with data obtained from three distinct sources: individual-level and social-network data from employees; use data from EMR system logs; and patient satisfaction data from patients and/or authorized decision-makers. Responses were obtained from 151 physicians and 8440 patient satisfaction surveys over the course of a 1-year period at the shakedown phase of an EMR system implementation.

Results

Physicians who were better connected, both directly and indirectly, to their peers—that is, other physicians—for advice on their work, used the system less than those who were less connected. In addition to such social network ties, demographic characteristics (gender and age), three personality characteristics (openness to experience, agreeableness and extroversion) and a key technology perception (perceived usefulness) predicted EMR system use.

Conclusions

For hospital administrators and other stakeholders, understanding the contributors to, and the relative importance of, various factors in explaining EMR system use, and its impact on patient satisfaction is of great importance. The factors identified in this work that influence a physician''s use of EMR systems can be used to develop interventions and applications that can increase physician buy-in and use of EMR systems.     

The feasibility of automating audit and feedback for ART guideline adherence in Malawi

Objective

To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi.

Materials and methods

We evaluated recommendations from Malawi''s ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure''s denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups.

Results

We analyzed 423 831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi''s ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled.

Discussion

It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs'' opportunities to reflect on their performance.

Conclusion

A moderate number of recommendations from Malawi''s ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings.     

High accuracy information extraction of medication information from clinical notes: 2009 i2b2 medication extraction challenge

Objective

Medication information comprises a most valuable source of data in clinical records. This paper describes use of a cascade of machine learners that automatically extract medication information from clinical records.

Design

Authors developed a novel supervised learning model that incorporates two machine learning algorithms and several rule-based engines.

Measurements

Evaluation of each step included precision, recall and F-measure metrics. The final outputs of the system were scored using the i2b2 workshop evaluation metrics, including strict and relaxed matching with a gold standard.

Results

Evaluation results showed greater than 90% accuracy on five out of seven entities in the name entity recognition task, and an F-measure greater than 95% on the relationship classification task. The strict micro averaged F-measure for the system output achieved best submitted performance of the competition, at 85.65%.

Limitations

Clinical staff will only use practical processing systems if they have confidence in their reliability. Authors estimate that an acceptable accuracy for a such a working system should be approximately 95%. This leaves a significant performance gap of 5 to 10% from the current processing capabilities.

Conclusion

A multistage method with mixed computational strategies using a combination of rule-based classifiers and statistical classifiers seems to provide a near-optimal strategy for automated extraction of medication information from clinical records.Many of the potential benefits of the electronic medical record (EMR) rely significantly on our ability to automatically process the free-text content in the EMR. To understand the limitations and difficulties of exploiting the EMR we have designed an information extraction engine to identify medication events within patient discharge summaries, as specified by the i2b2 medication extraction shared task.     

Topical treatment of actinic keratoses with potassium dobesilate 5% cream. A preliminary open-label study

Background

Fibroblast growth factor (FGF) is involved in skin tumorigenesis: it promotes cell viability, induces angiogenesis and stimulates invasiveness. Dobesilate is a drug that blocks the activity of FGF. The primary objective was to evaluate the efficacy and tolerability of potassium dobesilate 5% cream in the treatment of actinic keratoses.

Methods

Potassium dobesilate 5% cream was applied twice daily for 16 weeks to actinic keratosis lesions in 30 patients. The lesions were evaluated clinically at an initial baseline visit, at intermediate visits, and at 16 weeks of treatment.

Results

The use of potassium dobesilate 5% cream for 16 weeks induced complete regression in 70% of evaluated actinic keratoses, corresponding to grade I, II and III clinical variants, and a partial response (at least 75% reduction of lesions) in 20% of the cases.

Conclusion

Our preliminary trial shows that potassium dobesilate exerts anti-tumorigenic effects and may play a useful role in the chemoprevention of skin cancers.     

Influenza surveillance using electronic health records in the American Indian and Alaska Native population

Objective

Increasing use of electronic health records (EHRs) provides new opportunities for public health surveillance. During the 2009 influenza A (H1N1) virus pandemic, we developed a new EHR-based influenza-like illness (ILI) surveillance system designed to be resource sparing, rapidly scalable, and flexible. 4 weeks after the first pandemic case, ILI data from Indian Health Service (IHS) facilities were being analyzed.

Materials and methods

The system defines ILI as a patient visit containing either an influenza-specific International Classification of Disease, V.9 (ICD-9) code or one or more of 24 ILI-related ICD-9 codes plus a documented temperature ≥100°F. EHR-based data are uploaded nightly. To validate results, ILI visits identified by the new system were compared to ILI visits found by medical record review, and the new system''s results were compared with those of the traditional US ILI Surveillance Network.

Results

The system monitored ILI activity at an average of 60% of the 269 IHS electronic health databases. EHR-based surveillance detected ILI visits with a sensitivity of 96.4% and a specificity of 97.8% based on chart review (N=2375) of visits at two facilities in September 2009. At the peak of the pandemic (week 41, October 17, 2009), the median time from an ILI visit to data transmission was 6 days, with a mode of 1 day.

Discussion

EHR-based ILI surveillance was accurate, timely, occurred at the majority of IHS facilities nationwide, and provided useful information for decision makers. EHRs thus offer the opportunity to transform public health surveillance.     

Use of exhaled nitric oxide in children with bronchial asthma

Background

Inflammation is an important aspect of the pathophysiology of bronchial asthma and measurement of inflammatory markers of airways can aid in management. Nitric oxide measurement in exhaled breath is a non-invasive method of determining airway inflammation which can be used in assessing severity and response to treatment in children with bronchial asthma.

Methods

Thirty children in the age group 6–14 years with previously or newly diagnosed bronchial asthma reporting for the first time to a tertiary care hospital constituted the study group. Assessment was done by history, clinical examination, spirometry and measurement of fractional excretion of nitric oxide (FeNO) before commencement of treatment as per standard guidelines and on follow up at 2 to 4 weeks intervals for a minimum of three times.

Results

There was significant correlation between FeNO values, spirometry parameters and clinical profile in the first visit before the initiation of therapy. Children with higher FeNO in the first visit responded better to Inhaled Corticosteroids (ICS) with good clinical and spirometry responses and fall in FeNO on second visit. However, in subsequent visits no significant correlation was observed between clinical control, FeNO levels and spirometry.

Conclusion

High FeNO values at first presentation could give us a clue as to whether or not a child would respond to ICS but FeNO monitoring may not be helpful in long term follow up as various other factors can affect its value.     

A Randomized Trial of Electronic Clinical Reminders to Improve Medication Laboratory Monitoring

Objective

Recommendations for routine laboratory monitoring to reduce the risk of adverse medication events are not consistently followed. We evaluated the impact of electronic reminders delivered to primary care physicians on rates of appropriate routine medication laboratory monitoring.

Design

We enrolled 303 primary care physicians caring for 1,922 patients across 20 ambulatory clinics that had at least one overdue routine laboratory test for a given medication between January and June 2004. Clinics were randomized so that physicians received either usual care or electronic reminders at the time of office visits focused on potassium, creatinine, liver function, thyroid function, and therapeutic drug levels.

Measurements

Primary outcomes were the receipt of recommended laboratory monitoring within 14 days following an outpatient clinic visit. The effect of the intervention was assessed for each reminder after adjusting for clustering within clinics, as well as patient and provider characteristics.

Results

Medication-laboratory monitoring non-compliance ranged from 1.6% (potassium monitoring with potassium-supplement use) to 6.3% (liver function monitoring with HMG CoA Reductase Inhibitor use). Rates of appropriate laboratory monitoring following an outpatient visit ranged from 14% (therapeutic drug levels) to 64% (potassium monitoring with potassium-sparing diuretic use). Reminders for appropriate laboratory monitoring had no impact on rates of receiving appropriate testing for creatinine, potassium, liver function, renal function, or therapeutic drug level monitoring.

Conclusion

We identified high rates of appropriate laboratory monitoring, and electronic reminders did not significantly improve these monitoring rates. Future studies should focus on settings with lower baseline adherence rates and alternate drug-laboratory combinations.     

A Randomized Effectiveness Trial of a Clinical Informatics Consult Service: Impact on Evidence-based Decision-making and Knowledge Implementation

Objective

To determine the effectiveness of providing synthesized research evidence to inform patient care practices via an evidence based informatics program, the Clinical Informatics Consult Service (CICS).

Design

Consults were randomly assigned to one of two conditions: CICS Provided, in which clinicians received synthesized information from the biomedical literature addressing the consult question or No CICS Provided, in which no information was provided.

Measurement

Outcomes were measured via online post-consult forms that assessed consult purpose, actual and potential impact, satisfaction, time spent searching, and other variables.

Results

Two hundred twenty six consults were made during the 19-month study period. Clinicians primarily made requests in order to update themselves (65.0%, 147/226) and were satisfied with the service results (Mean 4.52 of possible 5.0, SD 0.94). Intention to treat (ITT) analyses showed that consults in the CICS Provided condition had a greater actual and potential impact on clinical actions and clinician satisfaction than No CICS consults. Evidence provided by the service primarily impacted the use of a new or different treatment (OR 8.19 95% CI 1.04–64.00). Reasons for no or little impact included a lack of evidence addressing the issue or that the clinician was already implementing the practices indicated by the evidence.

Conclusions

Clinical decision-making, particularly regarding treatment issues, was statistically significantly impacted by the service. Programs such as the CICS may provide an effective tool for facilitating the integration of research evidence into the management of complex patient care and may foster clinicians’ engagement with the biomedical literature.     

Care transitions as opportunities for clinicians to use data exchange services: how often do they occur?

Background

The electronic exchange of health information among healthcare providers has the potential to produce enormous clinical benefits and financial savings, although realizing that potential will be challenging. The American Recovery and Reinvestment Act of 2009 will reward providers for ‘meaningful use’ of electronic health records, including participation in clinical data exchange, but the best ways to do so remain uncertain.

Methods

We analyzed patient visits in one community in which a high proportion of providers were using an electronic health record and participating in data exchange. Using claims data from one large private payer for individuals under age 65 years, we computed the number of visits to a provider which involved transitions in care from other providers as a percentage of total visits. We calculated this ‘transition percentage’ for individual providers and medical groups.

Results

On average, excluding radiology and pathology, approximately 51% of visits involved care transitions between individual providers in the community and 36%–41% involved transitions between medical groups. There was substantial variation in transition percentage across medical specialties, within specialties and across medical groups. Specialists tended to have higher transition percentages and smaller ranges within specialty than primary care physicians, who ranged from 32% to 95% (including transitions involving radiology and pathology). The transition percentages of pediatric practices were similar to those of adult primary care, except that many transitions occurred among pediatric physicians within a single medical group.

Conclusions

Care transition patterns differed substantially by type of practice and should be considered in designing incentives to foster providers'' meaningful use of health data exchange services.     

Electronic medical record systems are associated with appropriate placement of HIV patients on antiretroviral therapy in rural health facilities in Kenya: a retrospective pre-post study

Background and objective

There is little evidence that electronic medical record (EMR) use is associated with better compliance with clinical guidelines on initiation of antiretroviral therapy (ART) among ART-eligible HIV patients. We assessed the effect of transitioning from paper-based to an EMR-based system on appropriate placement on ART among eligible patients.

Methods

We conducted a retrospective, pre-post EMR study among patients enrolled in HIV care and eligible for ART at 17 rural Kenyan clinics and compared the: (1) proportion of patients eligible for ART based on CD4 count or WHO staging who initiate therapy; (2) time from eligibility for ART to ART initiation; (3) time from ART initiation to first CD4 test.

Results

7298 patients were eligible for ART; 54.8% (n=3998) were enrolled in HIV care using a paper-based system while 45.2% (n=3300) were enrolled after the implementation of the EMR. EMR was independently associated with a 22% increase in the odds of initiating ART among eligible patients (adjusted OR (aOR) 1.22, 95% CI 1.12 to 1.33). The proportion of ART-eligible patients not receiving ART was 20.3% and 15.1% for paper and EMR, respectively (χ²=33.5, p<0.01). Median time from ART eligibility to ART initiation was 29.1 days (IQR: 14.1–62.1) for paper compared to 27 days (IQR: 12.9–50.1) for EMR.

Conclusions

EMRs can improve quality of HIV care through appropriate placement of ART-eligible patients on treatment in resource limited settings. However, other non-EMR factors influence timely initiation of ART.