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PubMed2000

[Computer-assisted oral, maxillary and facial surgery].

BACKGROUND: Methods from the area of virtual reality are used in oral and maxillofacial surgery for the planning and three-dimensional individual simulation of surgeries. SIMULATION: In order to simulate complex surgeries with the aid of a computer, the diagnostic image data and especially various imaging modalities (CT, MRT, US) must be arranged in relation to each other, thus enabling rapid switching between the various modalities as well as the viewing of mixed images. Segmenting techniques for the reconstruction of three-dimensional representations of soft-tissue and osseous areas are required. We must develop ergonomic and intuitively useable interaction methods for the surgeon, thus allowing for precise and fast entry of the planned surgical intervention in the planning and simulation phase. SURGERY: During the surgical phase, instrument navigation tools offer the surgeon interactive support through operation guidance and control of potential dangers. This feature is already available today. Future intraoperative assistance will take the form of such passive tools for the support of intraoperative orientation as well as so-called tracking systems (semi-active systems) which accompany and support the surgeons' work. The final form are robots which execute specific steps completely autonomously. DISCUSSION: The techniques of virtual reality keep gaining in importance for medical applications. Many applications are still being developed or are still in the form of a prototype. However, it is already clear that developments in this area will have a considerable effect on the surgeon's routine work.

Computer Simulation↗
PubMed1991

Getting advance directives to the public: a role for emergency medicine.

Advance directives are becoming more common in the health care system in the United States. Advance directives include "living wills," "durable powers of attorney for health care," "do not resuscitate orders," and the newer "medical directive." They are designed to allow individuals to determine the course of their medical care in the event that they are no longer able to transmit the information to their physician. The US Supreme Court's recent Cruzan decision increased the importance of these legal instruments by declaring that "clear and convincing" evidence may be required by states in order to terminate life support in a patient unable to express his wishes about care. Unfortunately, for many reasons, advance directives are often not completed by those who might desire them. Only 9% of Americans have executed advance directives. Emergency physicians have the opportunity to assist their patients in advance by disseminating advance directives to those who have contact with the emergency department: patients, family members, friends, health care workers, emergency medical services personnel, and police. A plan is suggested that includes education, the availability of advance directives, personnel available to help with completion of the documents, and immediate entry of the directive into a medical chart, if requested. This is in conformance with a recent policy adopted by the American College of Emergency Physicians.

Advance Directives↗
PubMed2004

A trial of automated safety alerts for inpatient digoxin use with computerized physician order entry.

OBJECTIVE: Automated clinical decision support (CDS) has shown promise in improving safe medication use. The authors performed a trial of CDS, given both during computerized physician order entry (CPOE) and in response to new laboratory results, comparing the time courses of clinician behaviors related to digoxin use before and after implementation of the alerts. DESIGN: Alerts were implemented to notify of the potential risk from low electrolyte concentrations or unknown digoxin or electrolyte concentrations during CPOE. Alerts were also generated in response to newly reported hypokalemia and hypomagnesemia in patients given digoxin. MEASUREMENTS: Clinician responses to the alerts for six months were compared with responses to similar situations for six months prior to implementation. RESULTS: During CPOE, checking for unknown serum values increased after implementation compared with control at one hour: 19% vs. 6% for digoxin, 57% vs. 9% for potassium, and 40% vs. 12% for magnesium as well as at 24 hours (p < 0.01 for all comparisons). Electrolyte supplementation increased with newly reported hypokalemia and hypomagnesemia after implementation at one hour: 35% vs. 6% and 49% vs. 5% for potassium and magnesium, respectively, as well as at 24 hours (p < 0.01 for all comparisons). During CPOE, supplementation for hypokalemia was not improved, whereas supplementation for hypomagnesemia improved at one hour (p < 0.05). CONCLUSION: Overall, the alerts improved the safe use of digoxin. During CPOE, alerts associated with missing levels were effective. For hypokalemia and hypomagnesemia, the alerts given during CPOE were not as effective as those given at the time of newly reported low electrolytes.

Anti-Arrhythmia Agents↗
PubMed2003

Putting data integration into practice: using biomedical terminologies to add structure to existing data sources.

A major purpose of biomedical terminologies is to provide uniform concept representation, allowing for improved methods of analysis of biomedical information. While this goal is being realized in bioinformatics, with the emergence of the Gene Ontology as a standard, there is still no real standard for the representation of clinical concepts. As discoveries in biology and clinical medicine move from parallel to intersecting paths, standardized representation will become more important. A large portion of significant data, however, is mainly represented as free text, upon which conducting computer-based inferencing is nearly impossible. In order to test our hypothesis that existing biomedical terminologies, specifically the UMLS Metathesaurus and SNOMED CT, could be used as templates to implement semantic and logical relationships over free text data that is important both clinically and biologically, we chose to analyze OMIM (Online Mendelian Inheritance in Man). After finding OMIM entries' conceptual equivalents in each respective terminology, we extracted the semantic relationships that were present and evaluated a subset of them for semantic, logical, and biological legitimacy. Our study reveals the possibility of putting the knowledge present in biomedical terminologies to its intended use, with potentially clinically significant consequences.

Databases, Genetic↗
PubMedDate not supplied

Redundancy in a computer-generated order list: meeting the needs of nurses at various levels of practice expertise.

Paper-based clinical practice standards usually pertain to a single diagnosis or clinical condition. When a computerized provider order entry system applies multiple paper-based practice standards to one patient, it generates an order list containing redundant orders. Nurses respond to redundant orders on the basis of their level of nursing expertise with clinical care, computers, and practice standard domains. In this project, orders from three practice standards were manually combined to create a single order list, resulting in 15 duplicate and overlapping orders. A relational database was developed to test the automated removal of redundant orders. As expected, the automatically evaluated order list contained only one of each duplicate order and only the parent of each overlapping order group. Orders were then grouped by related system or function for readability. It is possible to automate the removal of duplicate and overlapping orders from an order list before display to the nurse.

Algorithms↗
PubMed1984

A semiquantitative score system for epidemiologic studies of fetal alcohol syndrome.

A total of 464 children of 323 women registered for alcoholism treatment in Budapest, Hungary, were studied in 1977-1979. A complex epidemiologic investigation was carried out using medical, psychological and anthropological data. The data were evaluated on the basis of a semiquantitative diagnostic scoring system for fetal alcohol syndrome. The score distribution curve for 301 children whose mothers imbibed during pregnancy was statistically significantly different from the score distribution curve for 163 children born to alcoholic mothers who remained abstinent during pregnancy and from the curve for a matched control group of 464 children. A significant difference was also found between the score distribution curves for the latter two groups. Twenty-five children of 301 drinkers (8.3%) scored below -30 points and were said to show typical manifestations of the syndrome. All of the mothers in this group imbibed large amounts of alcohol during pregnancy. A further 205 children of 464 alcoholic mothers (44.2%) scored between -30 and -10 points and were diagnosed as having an atypical form of the syndrome. Among the 205 children, 168 were the offspring of 301 drinkers (55.8%) and 37 were the offspring of 163 alcoholic females who were abstinent during pregnancy (22.7%). A stepwise discriminant analysis showed the best discriminating variables--in order of entry into the discriminant functions--to be current weight, nose-upper lip distance, behavioral disturbance (irritability), root of the nose, intelligence quotient, and palpebral fissure. The most important cause of fetal alcohol syndrome is the direct toxic effect of alcohol on the fetus.

Adult↗
PubMed2002

Prevention of prescription errors by computerized, on-line, individual patient related surveillance of drug order entry.

Computerized prescription of drugs is expected to reduce the number of many preventable drug ordering errors. In the present study we evaluated the usefullness of a computerized drug order entry (CDOE) system in reducing prescription errors. A department of internal medicine using a comprehensive CDOE, which included also patient-related drug-laboratory, drug-disease and drug-allergy on-line surveillance was compared to a similar department in which drug orders were handwritten. CDOE reduced prescription errors to 25-35%. The causes of errors remained similar, and most errors, on both departments, were associated with abnormal renal function and electrolyte balance. Residual errors remaining on the CDOE-using department were due to handwriting on the typed order, failure to feed patients' diseases, and system failures. The use of CDOE was associated with a significant reduction in mean hospital stay and in the number of changes performed in the prescription. The findings of this study both quantity the impact of comprehensive CDOE on prescription errors and delineate the causes for remaining errors.

Drug Prescriptions↗
PubMed2005

Human factors considerations relevant to CPOE implementations.

Although many studies have discussed the benefits of computerized provider order entry (CPOE), the actual number of hospitals using this technology remains low because of the many challenges that accompany the implementation of CPOE in healthcare facilities. It is common for user resistance to challenge implementation efforts. As more hospitals undertake CPOE implementations, a solid understanding of how to foster acceptance of CPOE is necessary to reap the benefits of medical error reduction, improved quality of care, and decreased healthcare costs. The principles and practices of human factors can be used to bolster physician satisfaction and increase usability, thereby increasing the chances of success for CPOE implementation. This article reviews the recent literature regarding CPOE and human factors, discussing how the human factors principles of task analysis, interface design, and computer supported cooperative work can be utilized to promote user acceptance and enhance CPOE implementation efforts.

Attitude of Health Personnel↗
PubMed1998

The vertically integrated pharmacy department.

Pharmacy's challenges and opportunities during a transition from a traditional hospital to an integrated health system are discussed with reference to the experience of a medical center in Vancouver, Washington. When a traditional hospital makes the transition to an integrated health system, pharmacy directors must consider how the core business will be affected, how pharmacy can add value, and how to best apply the skills of the pharmacy department. A well-trained staff that shares a view of the new organization and that can think outside the traditional hospital paradigm is required. New health systems will focus on quality-related outcomes at low cost and on disease management. Partnerships between providers and health care staff will be beneficial. To compete for capitated contracts, health systems will need to deliver services other than acute care to a broad geographic area, and primary care will be more prominent. There will be a shift toward outpatient services, and pharmacy departments will be under increasing pressure to develop outpatient pharmaceutical services. Pharmacy departments will also need to develop treatment guidelines for outpatients and to better manage drug costs by working with new business clients, improving continuity of care, increasing patients' access to care, having pharmacists provide hospice care, and implementing remote prescription-order entry. New health systems will need to have a clear understanding of how their core business is changing; the organizational strategy of a health system must include effective communication of change to staff members with the goal of overcoming traditional thinking.

Hospital Administration↗
PubMed2006

Optimising workflow in andrology: a new electronic patient record and database.

AIM: To improve workflow and usability by introduction of a new electronic patient record (EPR) and database. METHODS: Establishment of an EPR based on open source technology (MySQL database and PHP scripting language) in a tertiary care andrology center at a university clinic. Workflow analysis, a benchmark comparing the two systems and a survey for usability and ergonomics were carried out. RESULTS: Workflow optimizations (electronic ordering of laboratory analysis, elimination of transcription steps and automated referral letters) and the decrease in time required for data entry per patient to 71%+/-27%, P<0.05, lead to a workload reduction. The benchmark showed a significant performance increase (highest with starting the respective system: 1.3+/-0.2 s vs. 11.1+/-0.2 s, mean+/-SD). In the survey, users rated the new system at least two ranks higher over its predecessor (P<0.01) in all sub-areas. CONCLUSION: With further improvements, today's EPR can evolve to substitute paper records, saving time (and possibly costs), supporting user satisfaction and expanding the basis for scientific evaluation when more data is electronically available. Newly introduced systems should be versatile, adaptable for users, and workflow-oriented to yield the highest benefit. If ready-made software is purchased, customization should be implemented during rollout.

Andrology↗
PubMed1996

The impact of physician order entry on nursing roles.

This study examines the impact of physician order entry (POE) on nurses perceptions of work, quality of care, and nurse/physician communication. Four hospitals that have implemented a computerized order-entry system with POE were compared with four similar hospitals using the same computerized system with clerk order entry only. Three factors were extracted from the 29 item survey using principal component extraction with varimax rotation that accounted for 16.5%, 12.4% and 8.7% of the variance respectively. Three scales were constructed from these factors measuring perceptions of impact of the information system on the quality of care, job, control, and nurse/physician communication. Nurses working in the POE environment rated their computer system as having greater impact on the quality of care and lower ratings of perceived control than those working in non-POE environments. No differences were found between nurses working in POE environments and those working in POE in terms of their ratings of frequency of contact and ease of access to physicians.

Attitude of Health Personnel↗
PubMed2005

Primary care clinician attitudes towards ambulatory computerized physician order entry.

Ambulatory computerized physician order entry (ACPOE) represents one strategy to improve physician ordering practices, compliance with guidelines, and patient safety. We surveyed primary care physicians (PCPs) regarding attitudes towards ACPOE and its various features. Most PCPs did not have systems for tracking test results and were concerned about missed tests. However, there was concern that ACPOE might be time consuming, and only one-third of PCPs felt that ACPOE features would be very useful. Speed and workflow issues will be important contributors to the success of ACPOE. In addition, physician buy-in to the utility of its various features will need to be strengthened.

Ambulatory Care Information Systems↗
PubMed1994

A model for structured data entry based on explicit descriptional knowledge.

Clinical narratives in patient records are usually recorded in free text, limiting the use of this information for research, quality assessment, and decision support. This study focuses on the capture of clinical narratives in a structured format by supporting physicans with structured data entry (SDE). We analyzed and made explicit which requirements SDE should meet to be acceptable for the physician on the one hand, and generate unambiguous patient data on the other. Starting from these requirements, we found that in order to support SDE, the knowledge on which it is based needs to be made explicit: we refer to this knowledge as descriptional knowledge. We articulate the nature of this knowledge, and propose a model in which it can be formally represented. The model allows the construction of specific knowledge bases, each representing the knowledge needed to support SDE within a circumscribed domain. Data entry is made possible through a general entry program, of which the behavior is determined by a combination of user input and the content of the applicable domain knowledge base. We clarify how descriptional knowledge is represented, modeled, and used for data entry to achieve SDE, which meets the proposed requirements.

Artificial Intelligence↗
PubMedDate not supplied

Improving medical imaging report turnaround times: the role of technolgy.

At Southern Ohio Medical Center (SOMC), the medical imaging department and the radiologists expressed a strong desire to improve workflow. The improved workflow was a major motivating factor toward implementing a new RIS and speech recognition technology. The need to monitor workflow in a real-time fashion and to evaluate productivity and resources necessitated that a new solution be found. A decision was made to roll out both the new RIS product and speech recognition to maximize the resources to interface and implement the new solution. Prior to implementation of the new RIS, the medical imaging department operated in a conventional electronic-order-entry to paper request manner. The paper request followed the study through exam completion to the radiologist. SOMC entered into a contract with its PACS vendor to participate in beta testing and clinical trials for a new RIS product for the US market. Backup plans were created in the event the product failed to function as planned--either during the beta testing period or during clinical trails. The last piece of the technology puzzle to improve report turnaround time was voice recognition technology. Speech recognition enhanced the RIS technology as soon as it was implemented. The results show that the project has been a success. The new RIS, combined with speech recognition and the PACS, makes for a very effective solution to patient, exam, and results management in the medical imaging department.

Contract Services↗
PubMed2001

A computerized reminder system to increase the use of preventive care for hospitalized patients.

BACKGROUND: Although they are effective in outpatient settings, computerized reminders have not been proved to increase preventive care in inpatient settings. METHODS: We conducted a randomized, controlled trial to determine the effects of computerized reminders on the rates at which four preventive therapies were ordered for inpatients. During an 18-month study period, a computerized system processed on-line information for all 6371 patients admitted to a general-medicine service (for a total of 10,065 hospitalizations), generating preventive care reminders as appropriate. Physicians who were in the intervention group viewed these reminders when they were using a computerized order-entry system for inpatients. RESULTS: The reminder system identified 3416 patients (53.6 percent) as eligible for preventive measures that had not been ordered by the admitting physician. For patients with at least one indication, computerized reminders resulted in higher adjusted ordering rates for pneumococcal vaccination (35.8 percent of the patients in the intervention group vs. 0.8 percent of those in the control group, P<0.001), influenza vaccination (51.4 percent vs. 1.0 percent, P< 0.001), prophylactic heparin (32.2 percent vs. 18.9 percent, P<0.001), and prophylactic aspirin at discharge (36.4 percent vs. 27.6 percent, P<0.001). CONCLUSIONS: A majority of hospitalized patients in this study were eligible for preventive measures, and computerized reminders significantly increased the rate of delivery of such therapies.

Aspirin↗
PubMed2002

Computerized physician order entry and communication: reciprocal impacts.

Participant observation, focus group and oral history techniques were used to collect data from four distinctly different sites across the U.S. Data were examined initially to identify success factors for computerized physician order entry (CPOE) implementation. These data, reexamined for communication issues, revealed significant impacts on communication channels and relationships unanticipated by the implementers. Effects on physician-nurse interactions, pharmacy roles, and patient communications that vary by time and location were noted. The importance of robust bi-directional information channels between administration and staff was demonstrated to be potentially "mission-critical." The recommendation for implementers is "Plan to be surprised." Careful planning and pre-work are important but, no matter how much an institution prepares for the upheaval of CPOE, unforeseen consequences are inevitable. The presence of a prepared and capable implementation support group is essential.

Clinical Laboratory Information Systems↗
PubMedDate not supplied

Promoting the online use of radiology appropriateness criteria.

Radiology appropriateness criteria and practice guidelines seek to promote the cost-effective use of radiology procedures and interventions and can be most useful when integrated with electronic patient records and order-entry systems. The task of translating practice guidelines into computer-based formats can highlight deficiencies and lead to revisions that make them more useful. Computer-based practice guidelines can include additional didactic material, such as images, videos, sounds, simulations, and links to bibliographic databases. Given patient data, information systems can select the most appropriate intervention automatically; some systems can function autonomously. Knowledge representation schemes can make appropriateness criteria available across a wide variety of computer platforms. Internet-based tools can allow developers to collaborate across an institution or around the globe. Information systems can bring appropriateness criteria to physicians at the point of care. The use of standardized approaches is important to ensure that appropriateness criteria reach the broadest possible audience and that such efforts can be incorporated easily into automated systems.

Artificial Intelligence↗
PubMed2004

Bridging the gap: the Virtual Chemotherapy Unit.

Due to the complexity of pediatric chemotherapy administration, systems promoting safety must be utilized. Computerized order entry has been proven to reduce errors in the ordering of chemotherapeutic agents. A task force (the Breakthrough Committee) at The Children's Hospital of Philadelphia (CHOP) evaluated systems and identified the need to streamline the chemotherapy admission process from the outpatient clinic to the inpatient unit. In the outpatient setting chemotherapy orders were handwritten, whereas inpatient orders were computerized. Patients due for chemotherapy admissions were unable to start chemotherapy until they were physically admitted to an inpatient bed. In many cases, patients would not start receiving chemotherapy until late in the evening or even overnight. The Breakthrough Committee created the Virtual Chemotherapy Unit (Virtual Unit), which standardizes the ordering and documentation for all chemotherapy admissions. As per its name, the Virtual Unit is not an actual hospital unit but merely a location in the computer system where the patient is admitted prior to having a bed on the inpatient unit. Patients are now able to start chemotherapy infusions in the outpatient setting early in the day, rather than waiting until arrival to the inpatient unit. The nurses in the outpatient clinic are able to document chemotherapy administration online, giving the inpatient staff the ability to view the medications that were given. The Virtual Unit bridges the gap in chemotherapy ordering and documentation by utilizing 1 online episode per patient admission. Oncology nurses at CHOP played a fundamental role in the creation of the Virtual Unit. Nurses identified situations with potential for error in the ordering and administration of chemotherapy. These scenarios were analyzed and used in creating a safer system.

Antineoplastic Agents↗