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Biomedical subjects

Gilad J Kuperman

Publications and source records attributed to Gilad J Kuperman.

At least 19 recordsLinked to original sources
PubMed2007

To what extent do pediatricians accept computer-based dosing suggestions?

OBJECTIVE: Pediatric medication errors occur frequently among hospitalized patients and are often related to dosing. Computerized physician order entry systems with decision support can decrease dosing errors, as well as other types of errors; however, their use in pediatrics has not been extensively studied. Our objective was to determine physician acceptance of dosing and frequency decision support elements in an inpatient pediatric computerized physician order entry system at 1 academic medical center. PATIENTS AND METHODS: We performed a retrospective analysis of all electronic medication orders entered for pediatric inpatients at a large, urban teaching hospital between April 15, 2004, and December 31, 2004. Rates of physician acceptance of computerized physician order entry system-generated dosing and frequency suggestions were determined. RESULTS: We analyzed 54,413 orders in the computerized physician order entry system, of which 27,313 orders had dosing or frequency decision support. Of the orders with decision support, approximately one third (8822) were accepted exactly by prescribers. Of the 18,491 remaining orders, 8708 were changed for dose, 2466 for frequency, and 7317 for both. Among the 18,491 orders that were changed, the majority 11,322 deviated by a substantial amount (>50%) from the total daily dose initially suggested by the decision support feature. Overall, patient weight was missing 31.3% of the time, although patient age alone sometimes was sufficient for the computer to make a dosing suggestion. CONCLUSIONS: Although dosing-decision support systems have the potential to improve care, more work needs to be done to determine and optimize their effectiveness. Commercial vendors of dosing knowledge bases need to deliver effective products, because most health care organizations will not have the resources to customize decision support rules.

Adolescent↗
PubMed2006

Medication-related clinical decision support in computerized provider order entry systems: a review.

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

Contraindications↗
PubMed2006

Return on investment for a computerized physician order entry system.

OBJECTIVE: Although computerized physician order entry (CPOE) may decrease errors and improve quality, hospital adoption has been slow. The high costs and limited data on financial benefits of CPOE systems are a major barrier to adoption. The authors assessed the costs and financial benefits of the CPOE system at Brigham and Women's Hospital over ten years. DESIGN: Cost and benefit estimates of a hospital CPOE system at Brigham and Women's Hospital (BWH), a 720-adult bed, tertiary care, academic hospital in Boston. MEASUREMENTS: Institutional experts provided data about the costs of the CPOE system. Benefits were determined from published studies of the BWH CPOE system, interviews with hospital experts, and relevant internal documents. Net overall savings to the institution and operating budget savings were determined. All data are presented as value figures represented in 2002 dollars. RESULTS: Between 1993 and 2002, the BWH spent $11.8 million to develop, implement, and operate CPOE. Over ten years, the system saved BWH $28.5 million for cumulative net savings of $16.7 million and net operating budget savings of $9.5 million given the institutional 80% prospective reimbursement rate. The CPOE system elements that resulted in the greatest cumulative savings were renal dosing guidance, nursing time utilization, specific drug guidance, and adverse drug event prevention. The CPOE system at BWH has resulted in substantial savings, including operating budget savings, to the institution over ten years. CONCLUSION: Other hospitals may be able to save money and improve patient safety by investing in CPOE systems.

Academic Medical Centers↗
PubMed2005

Improving acceptance of computerized prescribing alerts in ambulatory care.

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians.

Adult↗
PubMed2005

Guided prescription of psychotropic medications for geriatric inpatients.

BACKGROUND: Inappropriate use or excessive dosing of psychotropic medications in the elderly is common and can lead to a variety of adverse drug events including falls, oversedation, and cognitive impairment. METHODS: We developed a database of psychotropic medication dosing and selection guidelines for elderly inpatients. We displayed these recommendations to physicians through a computerized order entry system at a tertiary care academic hospital. The system was activated for 2 of 4 six-week study periods in an off-on-off-on pattern. Main outcome measures were agreement with the recommended daily dose for the initial drug order, incidence of dosing at least 10-fold greater than the recommended daily dose, prescription of nonrecommended drugs, inpatient falls, altered mental status as measured by a brief nursing assessment, and hospital length of stay. RESULTS: A total of 7456 initial orders for psychotropic medications were prescribed for 3718 hospitalized elderly patients with a mean +/- SD age of 74.7 +/- 6.7 years. The intervention increased the prescription of the recommended daily dose (29% vs 19%; P<.001), reduced the incidence of 10-fold dosing (2.8% vs 5.0%; P<.001), and reduced the prescription of nonrecommended drugs (10.8% vs 7.6% of total orders; P<.001). Patients in the intervention cohort had a lower in-hospital fall rate (0.28 vs 0.64 falls per 100 patient-days; P = .001). No effect on hospital length of stay or days of altered mental status was found. CONCLUSION: A geriatric decision support system for psychotropic medications increased the prescription of recommended doses, reduced the prescription of nonrecommended drugs, and was associated with fewer inpatient falls.

Accidental Falls↗
PubMed2005

Comprehensive analysis of a medication dosing error related to CPOE.

This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.

Aged↗
PubMed2005

Managing the alert process at NewYork-Presbyterian Hospital.

Clinical decision support can improve the quality of care, but requires substantial knowledge management activities. At NewYork-Presbyterian Hospital in New York City, we have implemented a formal alert management process whereby only hospital committees and departments can request alerts. An explicit requestor, who will help resolve the details of the alert logic and the alert message must be identified. Alerts must be requested in writing using a structured alert request form. Alert requests are reviewed by the Alert Committee and then forwarded to the Information Systems department for a software development estimate. The model required that clinical committees and departments become more actively involved in the development of alerts than had previously been necessary. In the 12 months following implementation, 10 alert requests were received. The model has been well received. A lot of the knowledge engineering work has been distributed and burden has been removed from scarce medical informatics resources.

Decision Support Systems, Clinical↗
PubMed2005

Improving override rates for computerized prescribing alerts in ambulatory care.

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. We developed a selective knowledge base of only clinically significant drug alerts and designated only critical-high severity alerts to be interruptive to clinician workflow (a tiered approach). Using this approach, we were able to achieve a 67% clinician accept rate for ambulatory computerized prescribing alerts.

Ambulatory Care Information Systems↗
PubMed2004

Characteristics and consequences of drug allergy alert overrides in a computerized physician order entry system.

OBJECTIVE: The aim of this study was to determine characteristics of drug allergy alert overrides, assess how often they lead to preventable adverse drug events (ADEs), and suggest methods for improving the allergy-alerting system. DESIGN: Chart review was performed on a stratified random subset of all allergy alerts occurring during a 3-month period (August through October 2002) at a large academic hospital. MEASUREMENTS: Factors that were measured were drug/allergy combinations that triggered alerts, frequency of specific override reasons, characteristics of ADEs, and completeness of allergy documentation. RESULTS: A total of 6,182 (80%) of 7,761 alerts were overridden in 1,150 patients. In this sample, only 10% of alerts were triggered by an exact match between the drug ordered and allergy listed. Physicians' most common reasons for overriding alerts were "Aware/Will monitor" (55%), "Patient does not have this allergy/tolerates" (33%), and "Patient taking already" (10%). In a stratified random subset of 320 patients (28% of 1,150) on chart review, 19 (6%) experienced ADEs attributed to the overridden drug; of these, 9 (47%) were serious. None of the ADEs was considered preventable, because the overrides were deemed clinically justifiable. The degree of completeness of patients' allergy lists was highly variable and generally low in both paper charts and the CPOE system. CONCLUSION: Overrides of drug-allergy alerts were common and about 1 in 20 resulted in ADEs, but all of the overrides resulting in ADEs appeared clinically justifiable. The high rate of alert overrides was attributable to frequent nonexact match alerts and infrequent updating of allergy lists. Based on these findings, we have made specific recommendations for increasing the specificity of alerting and thereby improving the clinical utility of the drug allergy alerting system.

Decision Support Systems, Clinical↗
PubMed2004

Information technology as an infrastructure for patient safety: nursing research needs.

This article describes the process utilized to create research questions which promote technology as an infrastructure to enable safe nursing practice. Beginning with scenarios of safety problems related to nursing practice, the team identified information technology including hardware, software, and organizational and operational components to help improve the safety aspects addressed in the scenarios. Further discussed are characteristics of technology necessary at each step in the nursing process and finally recommendations are presented for various research questions that would be needed to enable research on the use of the proposed technologies.

Computers↗
PubMed2004

Design of a standards-based external rules engine for decision support in a variety of application contexts: report of a feasibility study at Partners HealthCare System.

This project explored functional requirements for an institution-wide method, at Partners HealthCare, for interpreting clinical knowledge for decision support. Such knowledge is currently incorporated in a variety of clinical applications, yet the methods of representation and of execution vary and the ability to author/edit the rules by human experts is limited. We expanded on a 2002 "Knowledge Inventory" at Partners to evaluate feasibility of designing a single representation approach entailing: (a) exploration of specific needs of different applications, in terms of kinds of response required (synchronous/asynchronous, time criticality, etc.), context (e.g., implied patient, time frame, or episode), and kinds of actions to be triggered; (b) kind of representation of knowledge and feasibility of casting knowledge in the form of if em leader then statements; and (c) data and knowledge resources used (implied data model, and particular knowledge sources and terminology sources). The result of analysis was to design an architecture to accomplish this goal. We also did preliminary analysis of requirements for authoring for such a representation, and for implementation.

Artificial Intelligence↗
PubMed2004

An analysis of inpatient nursing communications needs.

The health care environment is communications and information intensive. Nurses especially have communications as part of their routine activities, yet little is known about specific nursing communications needs and technologies that might address these needs. This project analyzed the specific communications needs of nurses at Massachusetts General Hospital (MGH) in Boston, MA, through focus group meetings, nursing staff interviews, and direct observation of unit communications. Based on these data, an ideal requirements list for a nursing communication system was created. Data were also gathered and analyzed from units piloting cell phones as nursing communications tools. On non-cell phone units we found that the bulk of communication activity is from the front desk operations associate to the nurse through a sub-optimal overhead paging system that is often unclear or inaudible. The pilot of cellular phones has demonstrated improvements in nursing communications at MGH and there are indications that other emerging technologies will be better able to address the ideal communication needs of nurses.

Academic Medical Centers↗
PubMed2003

Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality.

While evidence-based medicine has increasingly broad-based support in health care, it remains difficult to get physicians to actually practice it. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions, which should result in improved quality of care. Furthermore, providers make many errors, and clinical decision support can be useful for finding and preventing such errors. Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success. The goal of this report is to discuss these lessons learned in the interest of informing the efforts of others working to make the practice of evidence-based medicine a reality.

Decision Making, Computer-Assisted↗
PubMed2003

Computer physician order entry: benefits, costs, and issues.

Several analyses have detected substantial quality problems throughout the health care system. Information technology has consistently been identified as an important component of any approach for improvement. Computerized physician order entry (CPOE) is a promising technology that allows physicians to enter orders into a computer instead of handwriting them. Because CPOE fundamentally changes the ordering process, it can substantially decrease the overuse, underuse, and misuse of health care services. Studies have documented that CPOE can decrease costs, shorten length of stay, decrease medical errors, and improve compliance with several types of guidelines. The costs of CPOE are substantial both in terms of technology and organizational process analysis and redesign, system implementation, and user training and support. Computerized physician order entry is a relatively new technology, and there is no consensus on the best approaches to many of the challenges it presents. This technology can yield many significant benefits and is an important platform for future changes to the health care system. Organizational leaders must advocate for CPOE as a critical tool in improving health care quality.

Cost-Benefit Analysis↗
PubMed2003

A cost-benefit analysis of electronic medical records in primary care.

Electronic medical record systems improve the quality of patient care and decrease medical errors, but their financial effects have not been as well documented. The purpose of this study was to estimate the net financial benefit or cost of implementing electronic medical record systems in primary care. We performed a cost-benefit study to analyze the financial effects of electronic medical record systems in ambulatory primary care settings from the perspective of the health care organization. Data were obtained from studies at our institution and from the published literature. The reference strategy for comparisons was the traditional paper-based medical record. The primary outcome measure was the net financial benefit or cost per primary care physician for a 5-year period. The estimated net benefit from using an electronic medical record for a 5-year period was 86,400 US dollars per provider. Benefits accrue primarily from savings in drug expenditures, improved utilization of radiology tests, better capture of charges, and decreased billing errors. In one-way sensitivity analyses, the model was most sensitive to the proportion of patients whose care was capitated; the net benefit varied from a low of 8400 US dollars to a high of 140,100 US dollars . A five-way sensitivity analysis with the most pessimistic and optimistic assumptions showed results ranging from a 2300 US dollars net cost to a 330,900 US dollars net benefit. Implementation of an electronic medical record system in primary care can result in a positive financial return on investment to the health care organization. The magnitude of the return is sensitive to several key factors.

Computers↗
PubMed2003

A consensus statement on considerations for a successful CPOE implementation.

In May of 2001, thirteen experts on computerized provider order entry (CPOE) from around the world gathered at a 2-day conference to develop a consensus statement on successful CPOE implementation. A qualitative research approach was used to generate and validate a list of categories and considerations to guide CPOE implementation.

Decision Support Systems, Clinical↗
PubMed2003

Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool.

BACKGROUND: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at the time of data entry can be challenging. OBJECTIVE: To develop a problem list dictionary and search algorithm for an EMR system and evaluate its use. METHODS: We developed a problem list dictionary and lookup tool and implemented it in several EMR systems. A sample of 10,000 problem entries was reviewed from each system to assess overall coding rates. We also performed a manual review of a subset of entries to determine the appropriateness of coded entries, and to assess the reasons other entries were left uncoded. RESULTS: The overall coding rate varied significantly between different EMR implementations (63-79%). Coded entries were virtually always appropriate (99%). The most frequent reasons for uncoded entries were due to user interface failures (44-45%), insufficient dictionary coverage (20-32%), and non-problem entries (10-12%). CONCLUSION: The problem list dictionary and search algorithm has achieved a good coding rate, but the rate is dependent on the specific user interface implementation. Problem coding is essential for providing clinical decision support, and improving usability should result in better coding rates.

Algorithms↗