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PubMed2003

24. Clinical and laboratory assessment of immunity.

Clinicians order specific laboratory tests and interpret laboratory data that will be useful in establishing a diagnosis of immunodeficiency, either inherited (primary) immunodeficiencies or acquired (secondary) immunodeficiencies. The clinical immunologic evaluation of patients for immunodeficiency proceeds in an orderly fashion, from screening tests to sophisticated tests. The medical history and physical examination of the patient frequently provide clues guiding the level of entry into this testing program. Specific tests have been designed to screen for the four basic mechanisms of host defense: Antibody, T cell, phagocyte, and complement. The clinical immunology laboratory is a powerful adjunct to the clinician in the initial evaluation of immunodeficiency disorders and in the design of more sophisticated testing for selected patients.

Clinical Laboratory Techniques↗

PubMed2003

John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety: rewarding higher standards.

BACKGROUND: The Leapfrog Group is a consortium of more than 145 large health care purchasers committed to a common set of purchasing principles through which to leverage dramatic improvements in the safety, quality, and overall value of health care. Leapfrog purchasers mobilize consumers to seek out higher-quality providers, and they reward higher-quality providers. Leapfrog is primarily operationalized through Regional Roll-Outs--locally led purchaser efforts. PATIENT SAFETY RECOMMENDATIONS: The Leapfrog Group purchasers first focused on three patient safety practices, or "safety leaps," to reduce preventable medical errors--computer physician order entry, evidence-based hospital referral, and intensive care unit (ICU) physician staffing. Leapfrog's leaps are refined and updated annually on the basis of evidence and input from experts in the field. IMPACT ON PATIENT SAFETY: On the basis of survey results from the first 22 Regional Roll-Outs, as of September 2003, 4% of 633 hospitals reporting from the 22 regions fully met the CPOE standard, and an additional 17% of the 633 said they would meet the standard by 2005. Survey results also showed that 22% of the 605 hospitals in the 22 regions with ICUs met Leapfrog's ICU staffing recommendations and that an additional 5% would meet the standard by 2004. NEXT STEPS: In 2004 Leapfrog will launch new Regional Roll-Outs, bringing Leapfrog consumer education, hospital-specific information, and purchasing strategies to more communities nationwide.

Awards and Prizes↗

PubMed1993

Accuracy of bar codes versus handwriting for recording trauma resuscitation events.

STUDY OBJECTIVES: To compare the accuracy of computerized bar code data entry with conventional handwritten data entry during videotaped trauma resuscitations. SETTING: Laboratory; video simulation. TYPE OF PARTICIPANTS: Twenty-four emergency nurses. DESIGN: The nurses viewed videotapes of four different major trauma resuscitations during a single session. Each nurse recorded resuscitation events by handwritten entry in two cases and by bar code entry in another two. A computerized bar code system was designed specifically for contemporaneous charting of rapidly occurring events during trauma resuscitations. The handwritten and bar-coded records then were compared with a master list of events, and the number of entry errors were counted. Errors were defined as "omissions" (failing to record an event), "commissions" (recording an event that did not occur), or "inaccuracies" (errors in recording details of an event). ANALYSIS: Differences in the number of entry errors between the two recording methods were compared using unpaired t-tests. Differences in the number of errors after adjusting for the different nurses, different case being viewed, and order of viewing were analyzed using balanced analysis of variance techniques. P < .05 was considered significant. MAIN RESULTS: The mean +/- SEM number of total errors per record for bar codes was 2.63 +/- 0.24 compared with 4.48 +/- 0.30 for handwriting (P < .0001). The mean number of omissions per record for bar codes was 2.25 +/- 0.21 compared with 3.65 +/- 0.27 for handwriting (P = .0001). The mean number of inaccuracies per record for bar codes was 0.38 +/- 0.10 compared with 0.83 +/- 0.12 for handwriting (P = .0038). There were no commission-type errors. CONCLUSION: Computerized bar code data entry of trauma resuscitation events had significantly fewer entry errors than handwritten data entry in a laboratory setting. Potential advantages of bar code data entry include keyless data entry, automatic time-stamping, standardization of documentation, legibility of the medical record, and "point-of-care" data capture.

Electronic Data Processing↗

PubMed1996

A comprehensive inpatient discharge system.

Our group has developed a computer system that supports all phases of the inpatient discharge process. The system fills in most of the physician's discharge order form and the nurse's discharge abstract, using information available from sign-out, order entry, scheduling, and other databases. It supplies information for referrals to outside institutions, and provides a variety of instruction materials for patients. Discharge forms can be completed in advance, so that the patient is not waiting for final paperwork. Physicians and nurses can work on their components independently, rather than in series. Response to the system has been very favorable.

Continuity of Patient Care↗

PubMed2001

DIABCARE Quality Network in Europe--a model for quality management in chronic diseases.

The DIABCARE Q-Net project developed a complete and integrated information technology system to monitor diabetes care, according to the gold standards of the St Vincent Declaration Action Program. This is the first Telematic platform for standardized documentation on medical quality and evaluation across Europe, which will serve as a model for other chronic diseases. Quality development starts from the comparison of diabetes services, based on the key data on diabetes care in the basic information sheet. This is a 141 field form, which is to be completed once a year for each patient under the care of the diabetes team. The system performs an analysis of the local data and compares the data with peer teams by means of telecommunication of anonymous data. These data are collected regionally. At the next level these regional data are compared on a national basis across Europe using dedicated communication lines. National data can be compared transnationally by the use of the Internet and the DIABCARE benchmarking servers. These different lines are used according to the necessary security standards. Medical data are transferred via dedicated lines, aggregated data via the Internet. The architecture follows the open-platform concept in order to allow for heterogeneous technical environments. Already at the start of the project, the necessity for expanding the quality approach to telemedicine methodology was identified and included. For each level, specific programs are available to improve the performance of diabetes care delivery: DIABCARE data as client and DIABCARE server as regional and DIABCARE 'international server' as transnational server. Functioning pilots were established across all levels. The clients have been linked to the servers on a routine basis. According to the open architecture design, the various countries decided on different systems at the entry point: full system--Portugal; fax systems--Italy, Bavaria; implementation into doctor's office systems--Norway; paper forms and chip cards--France. This system can improve the local, regional and national diabetes care. Initiatives in several countries proved the feasibility of the system. The most extensive use, from Portugal, will be reported later in this paper. The exploitation of the DIABCARE Q-Net system will be performed with the DIABCARE International European Economic Interest Grouping as a co-ordinator and several commercial companies as contractors to market the products inside the system. The key project participants are: DIABCARE Office EURO, DIABCARE Portugal, DIABCARE France, DIABCARE Bavaria, DIABCARE UK, DIABCARE Netherlands, DIABCARE Norway, DIABCARE Italy, DIABCARE Sweden, DIABCARE Austria, DIABCARE Spain, GSF Research Centre for Health and Environment, FAST Research Institute for Applied Software Technology, Tromsø University Hospital, Stavanger Technical College, Technical University of Ilmenau, World Health Organisation (WHO), Regional Office for Europe.

Benchmarking↗

PubMed1986

Skills development by medical students and the influence of prior experience: a study using evaluation by students and self-assessment.

Research was carried out into the effectiveness of an innovative, problem-based introductory course which was designed to help medical students, within a traditional curriculum, to bridge the gap between theoretical study during the first 4 years and inservice training during the next 2 years. Comparison of exit and entry self-assessment ratings of students showed a marked rise for history-taking and physical examination and a smaller rise for diagnosis and patient management. Cross-study of these self-assessment ratings and the background variable of past medical training showed that prior active experience within the health care system appeared to have a favourable influence on both history-taking and more intellectual skills, notably diagnosis and patient management. History-taking, however, could be taught as effectively during the introductory course. This was not so for the more intellectual skills. The results of this research plead for early active experience within the health care system during the medical curriculum, in order to give the students more insight into the clinical relevance of their theoretical studies. Evaluation by the students of the teaching formats used to reach the learning objectives was favourable, especially of those formats related to concrete practical skills such as live simulated (programmed) patients. It was rather unfavourable to self-study facilities which provide more theoretical knowledge.

Clinical Competence↗

PubMed2003

Involving users in the implementation of an imaging order entry system.

Physician order entry is a powerful function of a computerized hospital information system. Although designed to be clinician-driven, the imaging section of the order entry system may not be designed optimally to engage the clinician with imaging procedures logically organized for the clinician's typical work patterns. There also may be resistance among overburdened clinicians in having to take the time to learn a new computer system and to assume "clerk's duties" of entering imaging orders. A potential means to address clinician opposition is to cooperatively engage each clinical service in the design of an imaging order entry system with customized menus for each service. This article reports a step-by-step process for the implementation of an imaging order entry system with specialized menus for an orthopedic service. This implementation process includes (1) identification of key personnel, (2) familiarization with the system, (3) discussion and dialogue between key personnel, (4) addressing specific problems, (5) education and orientation of the target group, (6) initial implementation, (7) feedback and improvement, (8) demonstration project (time study) to foster acceptance, and (9) ongoing enhancement.

Attitude to Computers↗

PubMed1998

On the way to a Web based hospital information system: concepts for the use of a medical data dictionary to present context sensitive information in an intranet environment.

Many authors have promoted the www-paradigm to build modern hospital information systems. However currently web-based applications are better suited to information "browsing" than to build complex data entry features. This prompted us to start with our first web based developments inside the Giessen University Hospital Information System in the field of pure presentation of stored knowledge and information. This article describes the concepts which will be used in Giessen to convert available information sources to the www paradigm and to implement context-sensitive knowledge presentation mechanisms inside the clinical information system. The approach is based upon a web-based medical data dictionary server. The data dictionary is used to map terms of interest, chosen from the clinical user during work with a HIS-application, to a semantic network of relationships. The dictionary server will follow those semantic links in order to find and display the webpages, which are linked to the subject.

Dictionaries as Topic↗

PubMed2005

Impact of an Electronic Health Record on oncologists' clinic time.

The use of Electronic Health Records (EHRs) has been widely advocated to transform health-care delivery by improving quality, safety, and efficiency. Compared to a paper-based system, EHRs offer better access to clinical data and facilitate order entry and decision support. However, the benefits provided by EHRs do not eliminate the need to assess how such systems alter clinician time utilization. A major barrier to EHR use has been the concern that the EHR will take longer to use than paper-based systems. Few studies have addressed this issue in specialty clinic settings. We performed a time-motion study to evaluate how oncologists' time utilization differed before and after EHR implementation.

Humans↗

PubMed2006

Computerised pathology test order entry reduces laboratory turnaround times and influences tests ordered by hospital clinicians: a controlled before and after study.

OBJECTIVE: To assess the impact of a computerised pathology order entry system on laboratory turnaround times and test ordering within a teaching hospital. METHODS: A controlled before and after study compared test assays ordered from 11 wards two months before (n = 97 851) and after (n = 113 762) the implementation of a computerised pathology order entry system (Cerner Millennium Powerchart). Comparisons were made of laboratory turnaround times, frequency of tests ordered and specimens taken, proportions of patients having tests, average number per patient, and percentage of gentamicin and vancomycin specimens labelled as random. RESULTS: Intervention wards experienced an average decrease in turnaround of 15.5 minutes/test assay (range 73.8 to 58.3 minutes; p<0.001). Reductions were significant for prioritised and non-prioritised tests, and for those done within and outside business hours. There was no significant change in the average number of tests (p = 0.228), or specimens per patient (p = 0.324), and no change in turnaround time for the control ward (p = 0.218). Use of structured order screens enhanced data provided to laboratories. Removing three test assays from the liver function order set resulted in significantly fewer of these tests being done. CONCLUSIONS: Computerised order entry systems are an important element in achieving faster test results. These systems can influence test ordering patterns through structured order screens, manipulation of order sets, and analysis of real time data to assess the impact of such changes, not possible with paper based systems. The extent to which improvements translate into improved patient outcomes remains to be determined. A potentially limiting factor is clinicians' capacity to respond to, and make use of, faster test results.

Chi-Square Distribution↗

PubMed1992

Cost containment and new priorities in the European community.

This article reports on the author's survey of the cost-control measures for health care in 12 European countries during the period from 1983 to 1990. Among these countries the greatest convergence was in the use of the budget as a system of control, reinforced by manpower controls. Budgets were constructed to restrict hospital costs and payments to doctors practicing outside of hospitals. Another strategy was cost sharing for purchase of drugs and, in some cases, for dentistry. Most countries took steps to control expensive medical equipment; others, to restrict entry to medical schools. The European experience demonstrates the technical feasibility of the government's controlling health care costs by regulating supply rather than demand. The key to Europe's success in the use of monopsony power, whereby one purchaser dominates the market. The author contends that regulation works in Europe and questions whether the United States can exert similar control over its coalition of insurers and providers in order to rein in its health care expenses.

Ambulatory Care↗

PubMed2003

Linking laboratory and pharmacy: opportunities for reducing errors and improving care.

A myriad of errors and lost improvement opportunities result from failure of clinical laboratory and pharmacy information systems to effectively communicate. Pharmacotherapy could benefit from enhanced laboratory-pharmacy linkage with respect to (1) drug choice (laboratory-based indications and contraindications), (2) drug dosing (renal or hepatic, blood level-guided adjustments), (3) laboratory monitoring (laboratory signals of toxicity, baseline and ongoing monitoring), (4) laboratory result interpretation (drug interfering with test), and (5) broader quality improvement (surveillance for unrecognized toxicity, monitoring clinician response delays). Linkages can be retrospective or real-time. Many organizations could benefit now by linking existing pharmacy and laboratory data. Greater improvement is possible through implementation of electronic order entry with real-time decision support incorporating linked laboratory and pharmacy data. While many guidelines, admonitions, and rules exist regarding drugs and the laboratory, substantial new knowledge and evidence in this area are needed. Focusing on these unmet needs and accompanying logistical challenges is a priority.

Clinical Laboratory Information Systems↗

PubMed2001

What's so special about medications: a pharmacist's observations from the POE study.

Observations from a multi-site observational study of physician order entry (POE) confirm that implementing POE is problematic, and suggest that implementing medication order entry is particularly difficult. A pharmacist participating in the study group sought to answer the question: What makes medications different? Analysis of themes specific to medication POE in this study's large data set was undertaken using a grounded theory approach. Emerging themes in the data are explored and include: (1) order complexity and the consequences of error; (2) impacts on professional roles; (3) prescribing needs in different settings; and (4) technology impact on medication administration. Awareness of potential roadblocks and lessons learned from previous implementation attempts should help organizations considering medication POE to optimize their own strategies.

Hospital Information Systems↗

PubMed2004

Computerized physician order entry in the critical care and general inpatient setting: a narrative review.

Computerized physician order entry (CPOE) is an increasingly used technologic tool for entering clinician orders, especially for medications and laboratory and diagnostic tests. Studies in hospitalized patients, including critically ill patients, have demonstrated that CPOE, especially with decision support, improves several outcomes. These improved outcomes include clinical measures such as reductions in serious medication errors and enhanced antimicrobial management of critically ill patients resulting in reduced length of stay. Additionally, several process outcomes have improved with CPOE such as increased compliance with evidence-based practices, reductions in unnecessary laboratory tests and cost savings in pharmacotherapeutics. Future studies are needed to demonstrate the benefits of more patient specific decision support interventions and the seamless integration of CPOE into a wireless, computerized medication administration system.

Clinical Trials as Topic↗

PubMed2000

Integration of a hematopoietic progenitor cell program using the ACT/DB database system.

Infusion of hematopoietic progenitor cells following high-dose chemotherapy is frequently used to treat patients with hematological malignancies and solid tumors. We have developed a comprehensive software system to monitor these patients once they are entered into an experimental protocol. The captured data encompasses all phases of progenitor cell therapy including progenitor cell mobilization and collection, stem cell processing, as well as cell infusion and engraftment kinetics. Particular attention was paid to the quality assurance and quality control functionality of the software during development of data entry forms and reports. The system was developed using the ACT/DB client-server database, which utilizes Microsoft Access as a front-end and accesses either an Oracle or SQL Server database. ACT/DB has been modified for deployment on the Internet in order to take advantage of Web-based technology. Information technology can help to integrate the diverse data requirements of complex therapeutic trials.

Database Management Systems↗

PubMed2004

How to design computerized alerts to safe prescribing practices.

BACKGROUND: Medication errors and preventable adverse drug events are common, and about half of medication errors occur during medication ordering. This study was designed to develop and evaluate medication safety alerts and processes for educating prescribers about the alerts. METHODS: At Kaiser Permanente Northwest, a group-model health maintenance organization where prescribers have used computerized order entry since 1996, qualitative interviews were conducted with 20 primary care prescribers. RESULTS: Prescribers considered alerts helpful for providing prescribing and preventive health information. More than half the interviewees stated that it would be unwise to let clinicians control or avoid safety alerts. Common frustrations were (1) being delayed by the alert, (2) having difficulty interpreting the alert, and (3) receiving the same alert repeatedly. Most prescribers preferred small-group educational sessions tied to existing meetings and having local physicians conduct education sessions. DISCUSSION: The findings were used to design a strategy for introducing and promoting the interventions, modifying the alert text and tools, and focusing the education on how clinicians could use the alerts effectively.

Attitude of Health Personnel↗

PubMed2005

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients.

BACKGROUND: Critically ill patients require rapid care, yet they are also at risk for morbidity from the potential complications of that care. Computerized physician order entry (CPOE) is advocated as a tool to reduce medical errors, improve the efficiency of healthcare delivery, and improve outcomes. Little is known regarding the essential attributes of CPOE in the intensive care unit (ICU). OBJECTIVE: To assess the effect of CPOE on ICU patient care. DESIGN: Retrospective before and after cohort study. SETTING: An academic ICU. PATIENTS: Patients admitted to the ICU during use of the initial CPOE application and those admitted after its modification. INTERVENTIONS: Comprehensive order interface redesign improving clarity, specificity, and efficiency. MEASUREMENTS: Orders for complex ICU care were compared between the two groups. In addition, the use of higher-efficiency CPOE order paths was tracked. RESULTS: Patients treated with both the initial and modified CPOE system were similar for all measured characteristics. With the modified CPOE system, there were significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management. There was also a significant increase in orders executed through ICU-specific order sets after system modifications. LIMITATIONS: This retrospective study cannot assess issues related to learner expertise and is meant to only suggest the importance of developing CPOE systems that are appropriate for specialty care environments. CONCLUSION: Appropriate CPOE applications can improve the efficiency of care for critically ill patients. The workflow requirements of individual units must be analyzed before technologies like CPOE can be properly developed and implemented.

Computer Graphics↗

PubMed1996

Acute renal failure in intensive care units--causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. French Study Group on Acute Renal Failure.

OBJECTIVE: To assess the causes, the prognostic factors, and the outcome of patients with severe acute renal failure. DESIGN: Prospective, multicenter study. SETTING: Twenty French multidisciplinary intensive care units (ICUs). PATIENTS: All patients with severe acute renal failure were prospectively enrolled in the study for a 6-month period. Severe acute renal failure was defined by the following criteria: a) a serum creatinine concentration of > or = 3.5 mg/dL ( > or = 310 mumol/L) and/or a blood urea nitrogen concentration of > or = 100 mg/dL ( > or = 36 mmol/L); or b) an increase in blood urea nitrogen or serum creatinine concentration, such that the concentration is 100% above the baseline value in patients with previous chronic renal insufficiency (serum creatinine concentration of > 1.8 mg/dL [ > 150 mumol/L]), excluding those patients with a basal serum creatinine concentration of > 3.4 mg/dL ( > 300 mumol/L). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, sex, previous health status and preexisting organ dysfunction, and type and origin of acute renal failure were recorded. The Simplified Acute Physiology Score, the Acute Physiology and Chronic Health Evaluation (APACHE II) score, and the number of Organ System Failures were calculated on ICU day 1 and at the time of inclusion in the study. Prognostic factors were determined by univariate methods and stepwise logistic regression analysis. There were 360 patients in the study; 217 patients were admitted to the study at the time of ICU admission and 143 patients were admitted to the study after ICU admission. Only 41% of these patients were in good health 3 months before ICU entry. The reason for admission was medical in 78% of cases. The type of acute renal failure was prerenal (n = 16), renal (n = 282), or postrenal (n = 17). Renal replacement therapy was used in 174 patients. Two hundred ten (58%) patients died during the hospital stay. Using stepwide logistic regression, seven variables were predictive of death. These variables were advanced age, altered previous health status, hospitalization before ICU admission, delayed occurrence of acute renal failure, sepsis, oliguria, and severity of illness as assessed at the time of study inclusion by Simplified Acute Physiology Score, APACHE II, or Organ System Failure. CONCLUSIONS: The hospital mortality rate of patients with severe acute renal failure in patients requiring intensive care remains high. In order to compare patient groups in further trials concerning acute renal failure, recorded characteristics of the population should include age, previous health status, disease characteristics (initial or delayed acute renal failure, oliguria, sepsis), and the severity of the illness as assessed by physiologic scoring systems recorded at the time of study inclusion.

APACHE↗