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PubMed2005

Duke University Hospital uses rapid deployment to implement CPOE, clinical decision support.

These are trying times for advocates of computerized physician order entry (CPOE). A recent study in JAMA identified more than 20 types of error risks that were caused by a CPOE system. Market research indicates that fewer than 10% of provider organizations have implemented CPOE systems, with very slow growth forecast. But the rapid--and so far, successful--deployment of a CPOE with a clinical decision support component at Duke University Hospital shows a more positive side.

Decision Support Systems, Clinical↗
PubMed2005

The impact of electronic health records on time efficiency of physicians and nurses: a systematic review.

A systematic review of the literature was performed to examine the impact of electronic health records (EHRs) on documentation time of physicians and nurses and to identify factors that may explain efficiency differences across studies. In total, 23 papers met our inclusion criteria; five were randomized controlled trials, six were posttest control studies, and 12 were one-group pretest-posttest designs. Most studies (58%) collected data using a time and motion methodology in comparison to work sampling (33%) and self-report/survey methods (8%). A weighted average approach was used to combine results from the studies. The use of bedside terminals and central station desktops saved nurses, respectively, 24.5% and 23.5% of their overall time spent documenting during a shift. Using bedside or point-of-care systems increased documentation time of physicians by 17.5%. In comparison, the use of central station desktops for computerized provider order entry (CPOE) was found to be inefficient, increasing the work time from 98.1% to 328.6% of physician's time per working shift (weighted average of CPOE-oriented studies, 238.4%). Studies that conducted their evaluation process relatively soon after implementation of the EHR tended to demonstrate a reduction in documentation time in comparison to the increases observed with those that had a longer time period between implementation and the evaluation process. This review highlighted that a goal of decreased documentation time in an EHR project is not likely to be realized. It also identified how the selection of bedside or central station desktop EHRs may influence documentation time for the two main user groups, physicians and nurses.

Documentation↗
PubMed1997

Internal medicine residents' assessment of the subspecialty fellowship application process.

PURPOSE: The application process for fellowships in internal medicine subspecialties begins approximately 18 to 24 months before the start of training, requiring residents to decide on a career by the beginning of their second year of residency. The authors surveyed the internal medicine residents at Mount Sinai Hospital to assess their attitudes toward the fellowship application process. METHOD: A survey instrument was designed and given to all 121 residents in 1994-95. The instrument surveyed the residents' career plans and the timing of their decisions, inquired about the effect on their residency of applying for a fellowship, and asked the residents to assess and comment on the timing of the fellowship application process. RESULTS: In all, 80% (97) of the residents responded. Nearly two-thirds intended to apply for fellowship training; however, 17% of the first-year residents had changed their minds about their fellowship plans, and 50% of the second- and third-year residents had changed career plans. Whereas 79% of the first-year residents intended to apply "on time" during their second year, only 29% of the second-year residents intended to do so; 25% of the third-year residents planned to delay entry into a fellowship. Nearly two-thirds of the first- and second-year residents felt uncomfortable making an informed fellowship decision in their second year. In all, 60% of the residents felt they had to do research in order to get a competitive fellowship, and 68% said they had to change their assigned residency schedule to "get credentials" for fellowship applications. The consensus of nearly all the residents was that the timing of fellowship applications was much too early and should be moved to the middle of the third year. CONCLUSION: As the current system of applying for medical fellowships is generally experienced negatively by residents, the authors recommend that the process be moved to the middle of the third year and that medical schools, residency programs, and fellowship training programs reconsider the entire fellowship application process.

Attitude of Health Personnel↗
PubMed1999

A programmable rules engine to provide clinical decision support using HTML forms.

The authors have developed a simple method for specifying rules to be applied to information on HTML forms. This approach allows clinical experts, who lack the programming expertise needed to write CGI scripts, to construct and maintain domain-specific knowledge and ordering capabilities within WizOrder, the order-entry and decision support system used at Vanderbilt Hospital. The clinical knowledge base maintainers use HTML editors to create forms and spreadsheet programs for rule entry. A test environment has been developed which uses Netscape to display forms; the production environment displays forms using an embedded browser.

Artificial Intelligence↗
PubMed2003

Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges.

It is estimated that in 2000 almost 175 million people, or 2.9% of the world's population, were living outside their country of birth, compared to 100 million, or 1.8% of the total population, in 1995. As the global labour market strengthens, it is increasingly highly skilled professionals who are migrating. Medical practitioners and nurses represent a small proportion of highly skilled workers who migrate, but the loss of health human resources for developing countries can mean that the capacity of the health system to deliver health care equitably is compromised. However, data to support claims on both the extent and the impact of migration in developing countries is patchy and often anecdotal, based on limited databases with highly inconsistent categories of education and skills.The aim of this paper is to examine some key issues related to the international migration of health workers in order to better understand its impact and to find entry points to developing policy options with which migration can be managed.The paper is divided into six sections. In the first, the different types of migration are reviewed. Some global trends are depicted in the second section. Scarcity of data on health worker migration is one major challenge and this is addressed in section three, which reviews and discusses different data sources. The consequences of health worker migration and the financial flows associated with it are presented in section four and five, respectively. To illustrate the main issues addressed in the previous sections, a case study based mainly on the United Kingdom is presented in section six. This section includes a discussion on policies and ends by addressing the policy options from a broader perspective.

Journal Article↗
PubMed1997

Physician order entry system cuts error rate, improves path compliance, tracks data.

Installing physician order entry systems goes a long way to reducing expensive adverse drug events. Brigham and Women's Hospital's automated physician order entry system identifies potential drug interaction problems and flags dosage errors--plus it enables data collection to track prescribing practices and encourages physicians to follow standardized pathways. Here are the details on BWH's system, its study on how adverse drug events waste health care dollars, and advice on minimizing adverse events at your institution.

Adverse Drug Reaction Reporting Systems↗
PubMed2004

Case study: a health check-up for the corporate IT department.

As advances such as the electronic charting, closed-loop medication safety, physician order entry, consumer portals, electronic collaboration, and wireless access become the norm, central IS organizations are finding it difficult to keep pace. This challenge is exacerbated by declining margins, severe cost pressures, increased regulation, and added public scrutiny. Is your centralized IS organization healthy enough to meet the challenges presented by today's complex, demanding, dynamic healthcare delivery environments? How do you know? What factors do you consider?

Benchmarking↗
PubMed2003

Current and emerging business models in the health care information technology industry: a view from wall street.

When we think about health care IT, we don't just think about clinical automation with the movement to computerized physician order entry (CPOE), but also the need to upgrade legacy financial and administrative systems to interact with clinical systems. Technology acceptance by physicians remains low, and computer use by physicians for data entry and analysis remains minimal. We expect this trend to change, and expect increased automation to represent gradual change. The HCIT space is dynamic, with many opportunities, but also many challenges. The unique nature of the end market buyers, existing business models, and nature of the technology makes this a challenging but dynamic area for equity investment.

Investments↗
PubMed1986

Using the computer as a referral source to find the patient at nutritional risk.

The use of the computer-generated reports helped to identify the patient at nutritional risk on the basis of length of stay and diet order and permitted the dietitian to serve the patient in an appropriate and timely manner. Of 572 patients assessed in one year, 265, or 46%, were identified as needing nutrition assessment by the computer reports. As a result of increased visibility and increased medical record entries, awareness of the dietitian's expertise has increased. Several inservice presentations on tube-feeding products, tube-feeding administration, and TPN have been requested and given to medical, surgical, and intensive care nurses. Although specific data were not collected, a decrease in tube feeding wastage was noted. As a result of increased monitoring of tube feedings, a more efficient system of labeling tube feedings was designed. At Fairview General Hospital, use of the mainframe computer-generated patient lists has not only saved the dietitian valuable time in identifying patients with nutrition needs but also has afforded her the opportunity to practice current nutrition assessment on more patients. Possible future applications include microcomputer hook-up with the mainframe computer's data banks to complete nutrition assessment calculations.

Computers↗
PubMed1988

Grand Ducal Regulation authorizing the creation and use of a data bank on persons requesting work permits and their employers, 13 January 1987.

This Order authorizes the creation of a data bank with information about persons requesting work permits and their employers for the use of the Luxembourg Ministry of Labour and Employment Administration. The Order was issued in light of the Law of 28 March 1972, as amended, relative to the entry and residence of foreigners, the medical control of foreigners, and the employment of foreign labor.

Demography↗
PubMed2000

The use of a standardized terminology for comparison of free text and structured data entry.

The Minimal Standard Terminology (MST) for gastrointestinal endoscopy, the product of an international effort, is to be been used in a study comparing free text to structured reports of esophagogastroduodenoscopies (EGDs). This requires some assumptions and adaptations in order to map to the MST in a uniform and quantifiable manner. Initial mapping has suggested a number of problem areas which require further investigation.

Endoscopy, Digestive System↗
PubMed1997

Electronic forms: benefits drawbacks of a World Wide Web-based approach to data entry.

It has long been realized that, compared to paper-based records, electronic record systems provide many advantages in the healthcare environment, including increased availability, improved legibility, long-term accessibility, (potentially) greater completeness, data encoding, and automated decision support and analysis. In spite of these recognized benefits, collection of patient data at the point of service generally does not occur, in large part because each such effort usually requires application-specific software and hardware, and, most significantly, provider time. Given the presence of WWW browsers now available on nearly every desktop, the support and access concerns for data entry applications can be substantially lessened. Despite these advantages, there are also downsides to the use of the WWW for data entry, including user interface issues and security. At CPMC, we are currently using web-based forms to gather patient charge data from physical and occupational therapists. Benefits of this approach have included a 98.2% user compliance rate for at least weekly data entry, and the reduction of charge posting from an average of 24.3 days to 2.3 days following the date of service. Drawbacks to WWW-based applications have included increased security exposure and persistent human tendencies to enter data in batches rather than at the time of service. A final conclusion was that, in the absence of a strong central mandate, providers must perceive a clear benefit in order to be willing to learn and use a new technology.

Attitude to Computers↗
PubMed1995

Truncated biphasic pulses for transthoracic defibrillation.

BACKGROUND: Early defibrillation is the single most important factor for improving out-of-hospital ventricular fibrillation resuscitation rates. To achieve the earlier response times required for survival, typically < 6 minutes from time of collapse, it will be necessary to equip a far wider network of first responders (firefighters, police, and other individuals with responsibility for public safety) with small, lightweight, and inexpensive automatic external defibrillators (AEDs). An important step in reducing the size and cost of AEDs will be to improve defibrillation efficacy. Because biphasic waveform defibrillation has had a favorable impact on implantable cardioverter-defibrillators (ICDs), there are reasons to believe that biphasic waveforms would also improve transthoracic defibrillators. Our purpose, therefore, was to examine the efficacy of two different low-energy biphasic truncated waveforms referenced to a standard damped sine waveform for transthoracic defibrillation in humans. METHODS AND RESULTS: We prospectively and randomly compared the transthoracic defibrillation efficacy of two different truncated biphasic waveforms, 115 J (70 microF) and 130 J (105 microF), with that of a standard 200-J (36-microF, 28-mH) damped sine wave pulse using right anterior and left lateral thoracic pads (R2 Medical Systems) in 30 cardiac arrest survivors during transvenous ICD surgery. The right anterior patch electrode was used as the cathode and the left lateral thoracic pad as the anode. Transthoracic ventricular defibrillation rescue shocks were tested after a failed transvenous defibrillation shock delivered in the course of ICD testing. Each of the three different rescue shocks was tested in random order in each patient. All shocks were delivered at end expiration. The investigators responsible for determining transthoracic shock efficacy were blinded throughout the study to the transthoracic rescue waveform used. A total of 33 patients were considered for study, but three patients failed to satisfy all entry criteria or did not have a sufficient number of ventricular fibrillation inductions to allow for testing of all three waveforms. Percent efficacy for the three waveforms was then compared in the 30 patients who satisfied entry criteria and completed the protocol. The study population had a mean age of 61 +/- 11 years, with 22 (73%) being men. The mean left ventricular ejection fraction was 0.39 +/- 0.14. Coronary artery disease was present in 22 (73%). The 115-J (70-microF) biphasic pulse, the 130-J (105-microF) biphasic pulse, and the 200-J (36-microF, 28-mH) damped sine wave pulse were equally effective, resulting in a 97% first-shock ventricular defibrillation efficacy rate. Each waveform failed to defibrillate once, with each waveform failing in a different patient. CONCLUSIONS: The results of this study suggest that biphasic truncated transthoracic shocks of low energy (115 and 130 J) are as effective as 200-J damped sine wave shocks used in standard transthoracic defibrillators. This finding may contribute significantly to the miniaturization and cost reduction of transthoracic defibrillators, which could enable the development of a new generation of AEDs appropriate for an expanded group of out-of-hospital first responders and, eventually, layperson use.

Adult↗
PubMed2000

A test ordering system with automated reminders for primary care based on practice guidelines.

In this article we describe a real-time automated reminder system that has been developed to change Family Physicians' (FP) test ordering behavior. The system focuses on the appropriateness of test requests. We aim at using the system as a substitute for written feedback by human experts. The reminder system consists of a knowledge base, an order entry system and modules to provide passive and active support in the form of reminders to FPs. The system generates critical comments about the rationality of the test requests at the moment the FP orders a test that is not in line with national or regional guidelines. For the first validation of the knowledge base we compared the comments of a human expert to the comments of the reminder system on three random samples of test requests. The overall agreement in the subsequent validation rounds was 46, 60 and 69%. The corrections made in the knowledge base after each validation round resulted in a reminder system with 149 reminders concerning various medical problems. Due to the corrections in the knowledge base the reminder system reacts better over the subsequent validation rounds.

Diagnostic Tests, Routine↗
PubMed1980

Conference report. Patient re-entry into the community.

The National Assoication of Private Psychiatric Hospitals, in cooperation with 19 other national health-related associations, held a conference last June in Washington, D.C., on the issues involved in patient re-entry into the community. Representatives of the legal and medical professions, the insurance industry, allied health and mental health organizations, and federal, state, and local officials discussed the complex legal, social, and treatment problems that have resulted from the national movement of deinstitutionalization. As a start toward solving those problems, most of the speakers mentioned the need for partnerships among state, local, federal, and private providers, between the hospitals and community-based facilties, and among all mental health professionals. Several speakers emphasized the need for an effective advocacy system for the mentally ill and the need for mental health professionals to learn to use the political system in order to secure benefits for patients re-entering the community.

Chronic Disease↗
PubMed2003

Computerized physician order entry in U.S. hospitals: results of a 2002 survey.

OBJECTIVE: To determine the availability of inpatient computerized physician order entry in U.S. hospitals and the degree to which physicians are using it. DESIGN: Combined mail and telephone survey of 964 randomly selected hospitals, contrasting 2002 data and results of a survey conducted in 1997. MEASUREMENTS AVAILABILITY: computerized order entry has been installed and is available for use by physicians; inducement: the degree to which use of computers to enter orders is required of physicians; participation: the proportion of physicians at an institution who enter orders by computer; and saturation: the proportion of total orders at an institution entered by a physician using a computer. RESULTS: The response rate was 65%. Computerized order entry was not available to physicians at 524 (83.7%) of 626 hospitals responding, whereas 60 (9.6%) reported complete availability and 41 (6.5%) reported partial availability. Of 91 hospitals providing data about inducement/requirement to use the system, it was optional at 31 (34.1%), encouraged at 18 (19.8%), and required at 42 (46.2%). At 36 hospitals (45.6%), more than 90% of physicians on staff use the system, whereas six (7.6%) reported 51-90% participation and 37 (46.8%) reported participation by fewer than half of physicians. Saturation was bimodal, with 25 (35%) hospitals reporting that more than 90% of all orders are entered by physicians using a computer and 20 (28.2%) reporting that less than 10% of all orders are entered this way. CONCLUSION: Despite increasing consensus about the desirability of computerized physician order entry (CPOE) use, these data indicate that only 9.6% of U.S. hospitals presently have CPOE completely available. In those hospitals that have CPOE, its use is frequently required. In approximately half of those hospitals, more than 90% of physicians use CPOE; in one-third of them, more than 90% of orders are entered via CPOE.

Data Collection↗
PubMed2000

Assessing the implementation process.

A Computerized Patient Record System (CPRS) has many benefits and could improve health care outcomes. Reaping these benefits, however, is dependent on successful implementation of a provider order entry system. The literature supports substantial evidence that even systems that are usable, effective and reliable have not been adopted by the intended users. A successful implementation may be substantially a function of the degree to which the processes of care have changed to adapt to the new system. To ensure successful implementation we suggest monitoring the implementation process itself. The purpose of this paper is to report the methodology we developed for assessing how successfully a provider order entry system is being implemented. We adopt a model of diffusion of information technology developed by Fichman (1994) and expanded by Ash (1997). In this model, diffusion is characterized be three categories, "breadth" (infusion) and "depth" (diffusion) and "quality" (appropriateness of use). In this paper we discuss the typology of diffusion and describe specific measures designed to measure infusion and diffusion of a hospital information system.

Diffusion of Innovation↗
PubMed2005

Avoiding doubles in distributed nominative medical databases: optimization of the needleman and wunsch algorithm.

Difficulties in reconstituting patients' trajectory in the public health information systems are raised by errors in patients' identification processes. A crucial issue to achieve is avoiding doubles in distributed web databases. We explored Needleman and Wunsch (N&W) algorithm in order to optimize the properties of string matching. Five variants of the N&W algorithm were developed. The algorithms were implemented for a web Multi-Source Information System. This system was dedicated to tracking patients with End-Stage Renal Disease at both regional and national level. A simulated study database of 73,210 records was created. An insertion or suppression of each character of the original string was simulated. The rate of double entries was 2% given an acceptable distance set to 5 modifications. The search was sensitive and specific with an acceptable detection time. It detected up to 10% of modifications that is above the estimated error rate. A variant of the N&W algorithm designed as "cut-off heuristic", proved to be efficient for the search of double entries occurring in nominative distributed databases.

Algorithms↗