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This case demonstrates that, despite physician disregard of appropriate expert system warnings during computerized physician order entry, the distribution of alert "override" warnings to non-physician members of the clinical team can help avert adverse drug events.
Major trends in health information systems technology are described. The new paradigm for information systems is integrated, patient-centered computing. The computer system and files are designed around information-capture needs along the continuum of care instead of around charge capture or inventory. The need for patient information in the future will not be limited to the health system but will extend to work sites and homes. Health systems will move to full client-server architecture, higher-speed data transmission, and greater network capacity. Computing standards will be instituted nationwide. With changes in the economics of health care, physician order-entry systems are inevitable. Many health systems and system vendors are making progress in achieving the computer-based patient record (CPR); health systems will require the CPR if they are to be truly integrated. Trends in health care and health care information technology will require that pharmacists innovate and adapt as never before.
Terminologies are now software. They are key components of the integration of electronic patient records, decision support systems and information retrieval systems. To be used as software, the different types of content in traditional terminologies must be separated, which we term here: conceptual, linguistic, inferential and pragmatic. The conceptual knowledge at the heart of the terminology needs to be expressed formally in order to provide a dependable framework for the other types of knowledge. Information left implicit in most existing coding and classification systems must be made explicit. The test of the resulting terminologies is how well they support software for key functions: including data entry, information retrieval, mediation, indexing, and authoring.
BACKGROUND: Previous studies regarding the use of information technologies (IT) specifically among pediatricians and other physicians who treat children are lacking. As such, the objective of this study is to examine the use of electronic health record (EHR) systems and other IT applications among pediatricians and other child health providers (CHPs) in Florida. METHODS: We focus on pediatricians and other CHPs who responded to a state-wide physician survey of IT use. CHPs included general pediatricians, pediatric sub-specialists, and family physicians who self-reported a practice composition of at least 20% children. We compared general pediatricians to other CHPs and all CHPs (including pediatricians) to other physicians with respect to computer and internet availability, and to the use of personal digital assistants and EHRs. Those with an EHR were also compared regarding the availability of key functions available in their system. Statistical analyses included chi-square analysis and logistic regression models which controlled for numerous factors. RESULTS: A total of 4,203 surveys (28.2% response) including 1,021 CHPs, were returned. General pediatricians (13.7%) were significantly less likely to be using an EHR than both CHP family physicians (26.1%) and pediatric sub-specialists (29.6%; p < .001). In multivariate analysis, only general pediatricians were significantly less likely than other physicians to indicate the use of an EHR system (OR = .43; 95% C.I. = .29 - .64). Overall, CHPs were less likely to have key functions available in their EHR system including electronic prescribing (53.3% vs. 61.9%; p = .028), and electronic order entry (47.7% vs. 57.2%; p = .017) among others. General pediatricians and pediatric sub-specialists frequently lagged behind CHP family physicians with respect to key EHR functions. In contrast, CHPs had growth charts (51.3% vs. 24.0%; p < .001) and weight-based dosing functions (35.5% vs.22.7%; p < .001) more frequently than others. CONCLUSION: Physicians caring for children, and especially pediatricians, in Florida, are significantly slower than other doctors to adopt EHRs, and important electronic patient safety functionalities, into their office practices.
Physician order entry is a key factor in improving the quality of healthcare, while simultaneously reducing its cost. This paper describes an editor, a database, and a run-time system for creating and executing highly customized, user modifiable, order entry templates. The system allows non-programmers to create new order entry templates rapidly. Over the past 18 months, the templates have been used on over 2500 patients to enter over 40,000 separate orders.
Between 1979 and 1983, about 2 000 case reports of patients undergoing cardiac surgery were computerised. The availability of the centralised computer facilities of Hôpital Foch made this experiment possible. The computerised case notes were divided into several chapters in which a certain amount of data was compulsive and provision was made for the addition of further information. The data was introduced in the form of a numerical code out of a possible choice of 700 contained in a dictionary. A terminal located in the department was used to introduce the information or to consult a given case file directly. Statistical analysis of the cases was performed using APL language, the basis of which must be known in order to continue interrogation, the reply being almost immediate. Several examples of the use of the system are given: number of patients, average duration of surgery, characteristics of the ten oldest patients. Other studies include the use of double entry tables to determine the relationship between two variables such as the variation of cardiothoracic index and the degree of postoperative bleeding. Each case takes about 20 minutes to be coded; the number of cases not entered has decreased greatly year by year. The differences in language used in comparison with already existing systems are: the use of syntax, the possibility of dating events, an "open" dictionary. The main drawbacks of the system are: forgetting to code certain data and restrictions of interrogation (easier for fixed than for facultative data). The overall results have been clearly positive.(ABSTRACT TRUNCATED AT 250 WORDS)
Baylor College of Medicine has five Teen Health Clinics (THC) dispersed throughout Harris county. The population served by the clinics includes inner-city adolescent boys and girls 19 years of age and under. Patients receive services such as family planning, sexually transmitted disease screening and treatment, perinatal care, counseling, and support services. Adolescents may receive services at any one of the clinics at no cost to the adolescent or their dependents. Given the geographical distribution of the clinics and the reliance on paper-based records, client services cannot be provided efficiently or expeditiously. According to the statistics developed by Clinic staff, ineffective coordination of service needs and client schedules undermine the follow-up needed for effective care. For example, a counselor will often need to balance a school schedule, clinic visits, well baby follow-up, and the Best Friends Program for a new mother. In addition, the lack of ready access to patient information impairs the ability of clinical and social service staff to provide continuity of care. In fact, some cases of client dropout are attributable to these difficulties. We have developed the Collaborative Social and Medical Service Application (CSMSA) to facilitate the provision of social and medical services to this population. The CSMSA is a domain-specific application based on a robust infrastructure known as the Ambulatory Services Architecture (ASA). This system is designed to support integrated social and ambulatory care. The ASA is a Baylor developed application framework and architecture for the computerization of the patient medical record in the ambulatory care setting. The working environment for the CSMSA user is an integrated desktop which provides an operating environment for both third-party applications and the CSMSA, as well as a fundamental set of services. The integrated desktop services include a mechanism for object organization or grouping, a facility for the management of desktop objects including disposal and storage, and an embedded search utility to assist in the location of desktop objects as well as other application objects. The access control mechanism will provide the security for the desktop environment by requiring the user to log into and out of the environment. This security mechanism will also enable/disable CSMSA tools based on the user's role at the clinic. The CSMSA is designed to provide work process, functionality and data access appropriate to the responsibilities of the user, e.g., a THC clerk may have permission to view a patient's orders but does not have the facility to create an order. Patient context is defined through a patient browser containing the master patient index or a user defined patient list. Patient encounters are managed using forms based on the process for each encounter type (e.g., initial visit). Forms are used for data entry and for queries. Data entry forms are only committed to the patient database (i.e., making the patient data available to other users who have permission to access the data) when the user approves the data. The CSMSA provides a means to suspend an entry into a chart by saving incomplete or non-committed data entry forms as part of the desktop state which is restored when the user logs into the system. CSMSA was designed to provide a robust, expandable application capable of accommodating the changes in health care and social services delivery while encompassing evolving software standards and new technology. This goal was achieved using object-oriented methodologies and technologies, combined with an object-oriented database management system as the foundation of our server to facilitate the evolution of our data model.
PURPOSE: The purpose of this clinical project was to design and implement a computerized provider order entry system. BACKGROUND: Well-designed clinical computer systems can advance best practice and quality decision making, leading to improvements in patient and organizational outcomes. DESCRIPTION OF THE PROJECT: An Orders Design Group composed of clinical nurse specialists (CNSs), staff nurses, and information management personnel was formed. CNSs used competencies in the system sphere to lead the integration of the needs of patients, nurses, and organizations into new technologies. OUTCOME: CNSs facilitated implementation of a collaboratively designed interdisciplinary computerized order entry process. CONCLUSION: Evaluation of the design and implementation process demonstrated greater success with the order entry system under the leadership of CNSs than past initiatives where CNSs were not in leadership roles. IMPLICATIONS FOR NURSING PRACTICE: CNS competencies in designing and implementing innovative system-level solutions are key to clinical information systems design.
An order set is a predefined template that has been utilized in the standard care of hospitals for many years. While in the past, it took the form of pen and paper, today, it is, indeed, electronic. Within order sets are distinct ordering patterns that may yield fruitful results for clinicians and informaticians, alike. Protocols like there electronic counterpart, order sets, provide an 'indication' identifying the clinical scenario of the patient's condition when the ordering event occurred. This 'indication' is rarely captured by individual orders, and provides difficult challenges to developers of information systems. While mandating an 'indication' be entered for every medication or lab order makes the job much more tasking on the physician provider, it is appealing to researchers and accountants. We have attempted to bypasses that consideration by identifying ordering patterns that predict diagnostic related codes (DRGs) and diagnostic codes which would greatly facilitate the information gathering process and still provide a flexible and user friendly physician interface.
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.
Physician-operated order entry systems can bring great benefits to an institution. Such systems can improve the consistency, accuracy, safety, and cost-effectiveness of orders. When building or selecting order entry for an institution, consideration must be given to the many different scenarios in which orders are written and communicated. Transfer, post-op, pre-admission and discharge orders have different communication requirements from standard inpatient orders. In certain services, orders from a very limited set (such as warfarin orders) must be written frequently for a large number of patients. Intensive-care patients, chemotherapy patients, and others have particular requirements for ordering. A computerized order entry system should respond to these requirements in order to promote correct and efficient ordering. We present a number of these issues, their specific requirements, and the approach we have taken to ensure that the system both supports and enhances workflow.
Our objective was to assess the progression of osteoarthritis (OA) using scoring systems based on the anatomical changes recorded in the finger joints on standard radiographs and to test how far these scoring systems could be used to evaluate the effects of candidate "disease modifying osteoarthritis drugs" (DMOAD). The appearance and growth of osteophytes, narrowing of the joint space and subchondral bone changes allowed the classic OA-associated anatomical lesions to be used to score the progression of finger joint OA. Progression of OA in the finger joints was also assessed by the their evolution through previously described and predictable anatomical phases on standard X-rays. These phases were characterised by complete loss of the joint space preceding or coinciding with the appearance of subchondral cysts eroding the entire subchondral plate, and have been described in "inflammatory" or "erosive" OA. The erosive episodes were followed by processes of remodelling. In order to interfere with the progression of osteoarthritis, two chondroitin sulphates with possible DMOAD effects were used in two series of patients with OA of the finger joints. The patients were included in two separate randomised, double-blind placebo-controlled trials: 46 of them received chondroitin polysulphate and 34 received chondroitin sulphate. Eighty-five patients were kept on placebo medication and were used as controls. All 165 patients were followed for 3 years. Posteroanterior X-rays of the metacarpophalangeal and interphalangeal (IP) finger joints were obtained at the start of this prospective study and at yearly intervals thereafter. Almost 80% of the distal IP and 50% of the proximal IP were affected at study entry. In approximately 40% of the patients the classic picture of OA of the IP joints was complicated by manifest erosive OA changes. The two systems to score the progression of OA (Anatomical Lesion and Anatomical Phase Progression Score System) showed definite progression within 3 years of follow-up, especially in the IP joints. When compared with the placebo controls, none of the chondroitin sulphates prevented OA from occurring in previously normal finger joints. However, when the classic OA-associated anatomical lesions were considered, OA was less progressive in both active treatment groups. Furthermore, fewer patients from both chondroitin sulphate- and chondroitin polysulphate-treated groups developed "erosive" osteoarthritis. In conclusion, conventional radiographs can be used to assess the morbidity and progression of hand OA. The systems used to score the progression of finger joint OA allowed the DMOAD effects of both chondroitin sulphates to be evaluated. The data recorded during these pilot studies should help investigators to design future long-term clinical experiments.
We have developed and implemented an efficient method of managing routine patient care information as a programmable group order protocol. The purpose of protocol is to minimize a labor-intensive manual computer interaction by grouping clinically related routine orders as a single entity, thus to greatly speed up the time taken for manual entry such as keyboard stroke and/or mouse clicking. User programmability is added to facilitate insertion, deletion and update of order items to be a locally independent operation. A sequence of menu screen is also programmable when a change of standard operation is needed. Department specific order protocols are classified into four categories to improve user convenience. The degree of efficiency is measured by a number of key strokes and entry time. In most cases the time to enter order protocol with correction is found to take less than one minute with less than five key strokes. The method of order protocol entry clearly demonstrates end-user computing capability so that department specific requirements are resolved without resorting to computer department personnel. Flexibility of managing individual physician specific protocols is also beneficial enough to enhance the morale toward a hospital information system currently in use.
Very few empirical studies have been completed which verify the actual benefits of automation for nursing. This article provides an overview of the results and implications of five research studies undertaken at a Canadian Hospital to ascertain the impact of computerization on selected aspects of nursing. These studies found that nurses perceived few positive benefits for direct care givers when order entry, results reporting and care planning were automated. This article will be of particular interest to nurse administrators who are embarking on automation within their hospitals.
While the computer-based patient record (CPR) is considered essential technology for improving efficiency and quality of health care, the high cost of CPR implementation has been a major barrier to widespread acceptance of these systems. This paper describes a framework to evaluate the costs and benefits of implementing CPR systems in outpatient clinical settings. Return on investment (ROI), a measurement of the difference between the costs of and benefits from an investment, is one method to evaluate the economic implications of CPR. The major costs in acquiring a CPR system include the costs of hardware, software, networking, ongoing maintenance, installation and training, and opportunity costs. Benefits of CPR systems include improved productivity by reducing resource utilization or improving revenues; improved quality by providing convenient access to information at the point of care, computerized physician-order entry and decision support systems; and intangible benefits that can not be simply quantified in monetary terms, such as enhanced data capture and access, enhanced business management and improved legal and regulatory compliance. We believe that understanding the ROI framework will enable physicians to make informed strategic decisions regarding purchase and implementation of CPR systems in their practices.
Computer-based order entry is a powerful tool for enhancing patient care. A pilot project in the pediatric department of the Lilongwe Central Hospital (LCH) in Malawi, Africa has demonstrated that computer-based order entry (COE): 1) can be successfully deployed and adopted in resource-poor settings, 2) can be built, deployed and sustained at relatively low cost and with local resources, and 3) has a greater potential to improve patient care in developing than in developed countries.
BACKGROUND: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent medication errors. OBJECTIVES: The objectives were to describe interventions performed by a clinical pharmacist integrated into clinical wards with CPOE, to assess the acceptance of interventions by prescribers, and to describe factors associated with acceptance. METHODS: A 3-week prospective study was conducted in five wards of a 2000-bed French teaching hospital. RESULTS: During pharmacist review of medication orders and participation on physician rounds, six resident pharmacists provided interventions either conveyed orally to prescribers, using the computer system, or combining both methods. There were 221 pharmacist interventions concerning drug-drug interactions (27%), drug monitoring (17%) and computer-related problems (16%). Pharmacist interventions consisted of change of drug choice or dose adjustment (49%), drug monitoring (17%) and administration modality optimisation (14%). Interventions were provided solely via computer systems in 67% of cases. The rate of intervention acceptance was 47.1%. In multivariate analysis, acceptance was significantly associated with oral transmission (odds ratio [OR] = 6.46; 95% confidence interval [95% CI] [1.65-25.24]; p < 0.01), change of drug choice or dose adjustment recommendations (OR = 3.81; 95% CI [1.63-8.86]; p < 0.01) and administration modality optimisation recommendations (OR = 9.51; 95% CI [3.02-29.93]; p < 0.01). CONCLUSION: Communication method and nature of recommendation are factors associated with pharmacist intervention acceptance. CPOE is necessary to develop clinical pharmacy practice. However, only the integration of the pharmacist on the ward can guarantee a high level of acceptance of pharmacist interventions by prescribers.
OBJECTIVE: Substantial variations in adherence to guidelines for human immunodeficiency virus (HIV) care have been documented. To evaluate their effectiveness in improving quality of care, ten computerized clinical reminders (CRs) were implemented at two pilot and eight study sites. The aim of this study was to identify human factors barriers to the use of these CRs. DESIGN: Observational study was conducted of CRs in use at eight outpatient clinics for one day each and semistructured interviews were conducted with physicians, pharmacists, nurses, and case managers. MEASUREMENTS: Detailed handwritten field notes of interpretations and actions using the CRs and responses to interview questions were used for measurement. RESULTS: Barriers present at more than one site were (1) workload during patient visits (8 of 8 sites), (2) time to document when a CR was not clinically relevant (8 of 8 sites), (3) inapplicability of the CR due to context-specific reasons (9 of 26 patients), (4) limited training on how to use the CR software for rotating staff (5 of 8 sites) and permanent staff (3 of 8 sites), (5) perceived reduction of quality of provider-patient interaction (3 of 23 permanent staff), and (6) the decision to use paper forms to enable review of resident physician orders prior to order entry (2 of 8 sites). CONCLUSION: Six human factors barriers to the use of HIV CRs were identified. Reducing these barriers has the potential to increase use of the CRs and thereby improve the quality of HIV care.