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PubMed2006

The reinforcing effects of nicotine and stimulant medication in the everyday lives of adult smokers with ADHD: A preliminary examination.

Whereas the smoking prevalence rates in the general population are declining, rates among people diagnosed with attention-deficit/hyperactivity disorder (ADHD) continue to be elevated. Previous research has shown that nicotine may improve attention and mood, suggesting that nicotine may help ameliorate the attentional and emotional problems associated with ADHD. The present study examined the effects of nicotine with and without stimulant medication on ADHD symptoms, moods, and arousal in the everyday lives of smokers with ADHD. A total of 10 smokers with ADHD who were being treated with stimulant medication were asked to abstain from smoking while participating in the study. Participants underwent four conditions in randomized order: (a) Nicotine patch+stimulant medication, (b) nicotine patch only, (c) placebo patch+stimulant medication, and (d) placebo patch only. Each condition continued for 2 days, during which self-reports of ADHD symptoms and moods were obtained using electronic diaries. Lightweight ambulatory monitors recorded cardiovascular activity at each diary entry. Smoking abstinence was verified by expired carbon monoxide and salivary cotinine analysis. Results showed that nicotine patches and stimulant medication alone and in combination reduced difficulty concentrating and core ADHD symptoms compared with placebo patch only. Borderline improvement in impatience and self-control was seen with nicotine patch administration primarily on day 1. Nicotine patches also tended to elevate systolic and diastolic blood pressure compared with placebo patch during day 2. The findings suggest that smokers with ADHD experience nicotine-related reductions in ADHD symptoms during their everyday lives.

Administration, Cutaneous↗
PubMed2003

Empowerment of patients and communication with health care professionals through an electronic health record.

OBJECTIVE: The aim of this project was to design and develop a personal electronic health record (EHR) in order to support patient empowerment and additionally to enhance their communication and information exchange with health professionals through this EHR. METHOD: The functionality of a personal Electronic Healthcare Record (EHR) may vary from a simple web-based interface for interactive data entry and data review up to a much more powerful system additionally supporting electronic data/document communication between clinical information systems of primary care practitioners or hospitals and even reminder based support for the empowered citizen, to actively take care of his health, based on relevant disease management programs. It is one means to support patient empowerment, additionally supported by tools for building a patient community. Since storage and communication of data in an EHR comprises sensible personal health data, each of those functions needs specific security and access management requirements to be considered and implemented. RESULT: Clinical pilot projects are already done or under development.

Communication↗
PubMed1999

Perceptions of house officers who use physician order entry.

OBJECTIVE: Describe the perceptions of housestaff physicians about their experience using computerized physician order entry (POE) in hospitals. METHODS: Qualitative study using data from participant observation, focus groups, and both formal and informal interviews. Data were analyzed by three researchers using a grounded approach to identify patterns and themes in the texts. RESULTS: Six themes were identified, including housestaff education, benefits of POE, problems with POE, feelings about POE, implementation strategies, and the future of POE. CONCLUSION: House officers felt that POE assists patient care but may undermine education. They found that POE works best when tailored to fit local and individual workflow. Implementation strategies should include mechanisms for engaging housestaff in the decision process.

Attitude of Health Personnel↗
PubMed1993

Enhancing case management through computerized patient files.

The need for developing an organizational system for managing a large patient specialty population prompted the use of a computerized data entry and retrieval system. The use of a computerized system has facilitated patient case management, chart organization, and development of accessible data for research. Patient data fields (topic headings) are used for: (1) storing specific categories of patient data, (2) compiling lists for management and research, and (3) referring physician and patient/family contact information. Various lists can be compiled from the field data base in order to develop research and patient management lists. Patient management lists are used to track a patient's progress, provide quality assurance of care, and contribute researchable data. Also, patient information can be transferred automatically from the computerized daily management system into a computerized form letter. Individualized patient letters may be generated. Laboratory and test information from the last clinic or hospital visit can be mailed to families along with a handwritten personalized interpretation of their results by the CNS or physician.

Humans↗
PubMed2001

A computer based intervention on the appropriate use of arterial blood gas.

OBJECTIVE: To evaluate impact of a computer-based intervention on arterial blood gas (ABG) usage in an intensive care setting. DESIGN: Retrospectively examined, via mixed group analysis, the effects of the intervention on ABG usage in the intensive care unit (ICU). SUBJECTS: Included all clinicians who placed ABG orders in an ICU using the computerized physician order-entry system, as well as controls in non-order entry units. METHODS: Computer-based intervention presenting ordering clinician with patient s previous ABG values and limiting forward duration of tests ordered. Study spanned 12 weeks, 5 weeks pre-intervention and 7-weeks post-intervention. Of 8 ICUs, intervention implemented in 6, not implemented in 2. Data analyzed using the repeated measure ANOVA. RESULTS: Physicians entered <40% ABG orders. 376 ABGs per week processed pre-intervention, 387 per week post. Results nonsignificant with a p= 0.09. Orders placed declined from 1039 per week, Jan 2000 to 662 per week, April 2001. DISCUSSION: Study did not demonstrate significant change; limited power. Need longer study periods. Impact improved in the future by targeting physician users and tailoring intervention to specific work flow pattern of high utilization units.

Analysis of Variance↗
PubMed2004

Collection and retrieval of structured clinical data from electronic patient records in general practice. A first-phase study to create a health care database for research and quality assessment.

OBJECTIVE: To evaluate prerequisites, practicalities, attitudes and limitations related to the collection of structured clinical data in everyday general practice for use in the future establishment of a national registration network. DESIGN: Prospective study. SETTING: Primary health care centres in south-western Sweden. SUBJECTS: Fourteen participating general practitioners in five primary health care centres. MAIN OUTCOME MEASURES: Feasibility and workload involved in structured data entry and in the retrieval of data from different record systems. The accuracy of clinical data in terms of clinical variables, correctness and representativeness. RESULTS: All four record systems could deliver basic data on the patient population. One centre had to be excluded from further data retrieval because of limitations in the data retrieval export format. Collecting data in everyday practice was feasible with acceptable data accuracy and moderate workload. CONCLUSION: It was feasible to collect, retrieve and store structured clinical data with respect to accuracy and extra workload. Interest in a national registration network and an increasing demand for information about primary health care in order to optimise clinical practices and support research, creates prerequisites for establishing a valid and reliable database. However, developmental work focusing on classification limitations, coding tools and routines for data retrieval is necessary.

Data Collection↗
PubMed1996

Microbial contamination of blood conservation devices during routine use in the critical care setting: results of a prospective, randomized trial.

OBJECTIVES: To compare microbial contamination of two different blood conservation devices; to determine if there was an association between contamination of the blood conservation devices and clinical infections; to determine if there was a significant user preference for either of the two devices. DESIGN: Prospective, randomized trial. SETTING: Medical, neurosurgical, and spinal cord intensive care units of an urban, university hospital. PATIENTS: Forty patients who required clinically indicated intrafierial catheters placed at new sites. INTERVENTIONS: The two most widely available blood conservation devices at the time of the study (Venous Arterial blood Management Protection system [VAMP], Baxter Edwards Critical-Care, Irvine, CA; and Safe Draw, Ohmeda, Madison, WI) were chosen for comparison. After the normal 48 to 72 hrs of device use, the blood conservation systems were removed and semi-quantitative and quantitative cultures were taken from comparable sites of the two devices. Positive cultures from the patients were recorded and correlated with cultures obtained from the devices. In order to assess preference for either device, a survey tool was administered to the nursing staff who participated in the study. MEASUREMENTS AND MAIN RESULTS: Quantitative cultures from all sites cultured in both groups demonstrated mean colony counts of < 10(3) colony-forming units (cfu)/mL. There were no statistically significant differences in the colony counts at any of the sites compared between the two groups. There were no statistically significant relationships between positive cultures and patient age, gender, duration of device utilization, frequency of device entry, or the intensive care unit in which the study was conducted. In no circumstance did positive cultures from any of the blood conservation devices correlate with positive culture results from any sites of clinical infection. The clinical survey demonstrated a statistically significant preference for the VAMP system, which persisted despite increased experience with the Safe Draw system. CONCLUSIONS: The levels of microbial contamination noted in these devices were not consistent with clinical infection (defined as 10(3) cfu/mL on quantitative cultures). There was no significant difference in degree or pattern of contamination between the two devices. When utilized and changed according to the Centers for Disease Control guidelines, blood conservation devices are not harbors of infection in the critical care setting. Blood conservation devices can be used as part of a comprehensive blood conservation program in the critical care setting without undue concern for exacerbating infectious processes.

Blood Specimen Collection↗
PubMed2006

Exposure to automated drug alerts over time: effects on clinicians' knowledge and perceptions.

OBJECTIVE: We tested whether interval exposure to an automated drug alert system that included approximately 2000 drug-drug interaction alerts increased recognition of selected interacting drug pairs. We also examined other perceptions about computerized order entry. RESEARCH DESIGN: We administered cross-sectional surveys in 2000 and 2002 that included more than 260 eligible clinicians in each time period. SUBJECTS: We studied clinicians practicing in ambulatory settings within a Southern California Veterans Affairs Healthcare System and who responded to both surveys (97 respondents). MEASURES: We sought to measure (1) recognition of selected drug-drug and drug-condition interactions and (2) other benefits and barriers to using automated drug alerts. RESULTS: Clinicians correctly categorized similar percentages of the 7 interacting drug-drug pairs at baseline and follow-up (53% vs. 54%, P = 0.51) but improved their overall recognition of the 3 contraindicated drug-drug pairs (51% vs. 60%, P = 0.01). No significant changes from baseline to follow-up were found for the 8 interacting drug-condition pairs (60% vs. 62%, P = 0.43) or the 4 contraindicated drug-condition pairs (52% vs. 56%, P = 0.24). More providers preferred using order entry at follow-up than baseline (63% vs. 45%, P < 0.001). Signal-to-noise ratio remained the biggest reported problem at follow-up and baseline (54 vs. 57%, P = 0.75). In 2002, clinicians reported seeing a median of 5 drug alerts per week (representing approximately 12.5% of prescriptions entered), with a median 5% reportedly leading to an action. CONCLUSIONS: Interval exposure to automated drug alerts had little to no effect on recognition of selected drug-drug interactions. The primary perceived barrier to effective utilization of drug alerts remained the same over time.

Adult↗
PubMed2002

Identification and referral of families at high risk for cancer susceptibility.

PURPOSE: Obtainment of family history and accurate assessment is essential for the identification of families at risk for hereditary cancer. Our study compared the extent to which the family cancer history in the physician medical record reflected that entered by patients directly into a touch-screen family history computer program. PATIENTS AND METHODS: The study cohort consisted of 362 patients seen at a comprehensive cancer center ambulatory clinic over a 1-year period who voluntarily used the computer program and were a mixture of new and return patients. The computer entry was assessed by genetics staff and then compared with the medical record for corroboration of family history information and appropriate physician risk assessment. RESULTS: Family history information from the medical record was available for comparison to the computer entry in 69%. It was most often completed on new patients only and not routinely updated. Of the 362 computer entries, 101 were assigned to a high-risk category. Evidence in the records confirmed 69 high-risk individuals. Documentation of physician risk assessment (ie, notation of significant family cancer history or hereditary risk) was found in only 14 of the high-risk charts. Only seven high-risk individuals (6.9%) had evidence of referral for genetic consultation. CONCLUSION: This study demonstrates the need to collect family history information on all new and established patients in order to perform adequate cancer risk assessment. The lack of identification of patients at highest risk seems to be directly correlated with insufficient data collection, risk assessment, and documentation by medical staff.

Adult↗
PubMed2003

Web-based physician order entry: an open source solution with broad physician involvement.

Computerized physician order entry (CPOE) is a disruptive technology but holds great promise for reducing medical errors, improving workflow and in the long run, producing cost-savings. However, many studies have reported significant physician resistance to implementing CPOE. In this manuscript we present a two-prong strategy for quick implementation of CPOE: 1) a web-based deployment tool using an open source, secure environment that allows rapid development and deployment of content, and 2) the development of a large set of disease specific order sets and knowledge bases based on established vocabulary standards such as LOINC and SNOMED CT by teams of multidisciplinary content experts at the departmental level. The order sets can be viewed, edited and signed through a standard browser interface. This paper presents the conceptual framework and implementation requirements for such an endeavor.

Attitude of Health Personnel↗
PubMed2005

You've led the horse to water, now how do you get him to drink: managing change and increasing utilization of computerized provider order entry.

Community hospitals served by predominately private-practice physicians face difficult challenges in implementing computerized provider order entry (CPOE), but there are techniques and incentives that can be employed to change physician behavior Various techniques were used to increase CPOE utilization at Lehigh Valley Hospital, a three-campus, 750-bed tertiary community hospital in eastern Pennsylvania. Those techniques included presenting studies supporting CPOE as a way to improve patient care, recognizing support with small trinkets, providing individual access to computers, adding clinical decision support, and bringing peer pressure to bear Ultimately, financial compensation for the educational time required to learn to use and become proficient with the system was employed and had the greatest impact on behavior Measuring utilization of the CPOE system with data extracted from the hospital's clinical information system, CPOE utilization by physicians increased to 57 percent from 35 percent after a financial compensation program was initiated. Utilization declined to 42 percent several months after completing the first phase of the program and increased to 54 percent after a second phase was initiated.

Attitude to Computers↗
PubMed2003

Assessment of medication errors that involved drug allergies at a university hospital.

OBJECTIVES: To determine the reporting accuracy of true patient-related allergies to drugs in a large teaching institution (908 licensed beds), and to identify factors contributing to medication errors that involved drug allergies. Of particular interest was the accuracy of allergy information in the medical record and the occurrence of medication errors that involved penicillin antibiotics. METHODS: From a sample population of 340 patients, 50 adult patients admitted to our university-affiliated hospital who met criteria and had an allergy to selected drugs that was documented in the hospitalwide computer system were randomly selected and interviewed to determine the timing, nature, and extent of the reaction. Furthermore, data were collected from identified Medication Error Reports when an agent was prescribed for a patient with a reported allergy to that agent or class. Prospective data collection was conducted from November 2000-February 2001. Using the information obtained by the patient interview and chart documentation, we assessed the reported allergy. In addition, contributing factors for medication errors that involved drug allergies were identified. RESULTS: Of the sample population, 133 patients (39%) reported allergies to at least one drug. Allergies to beta-lactams, sulfonamides, and opioid narcotics were reported in 12.6% (43 patients), 9.1% (31), and 14.4% (49) of the sample population, respectively. Most agents involved in medication errors were beta-lactam antibiotics, with an overwhelming number of these errors due to piperacillin-tazobactam (51.4%, 36 errors). Other drugs involved were ampicillin (10%, 7 errors), other beta-lactams (24.3%, 17 errors), opioid narcotics (10%, 7 errors), and sulfonamides (4.3%, 3 errors). Most contributing factors were classified as "MD [prescribing physician] not aware of allergy." CONCLUSION: These results suggest a need for ensuring that prescribers review each patient's allergy profile before order entry.

Adult↗
PubMed2003

Methodology for evaluating physician order entry (POE) implementations.

The body of physician order entry (POE) implementations literature uses statistical evaluation methods to demonstrate changes in specified variables after POE implementation. To understand and manage the holistic impact of POE on the health care institution, a methodology that utilizes feedback to guide the POE implementation towards the satisfaction of stakeholder objectives is presented. Stakeholders jointly define quantitative and qualitative metrics for their objectives, establish target value vectors for the metrics that represent acceptable implementation outcomes and specify evaluation milestones. These are used to compare pre- and post-POE implementation clinical performance, enabling a socio-technical feedback-improvement cycle. A case study is provided to illustrate how the methodology is being used at Sunnybrook and Women's College Health Science Centre in Toronto, Canada.

Drug Prescriptions↗
PubMed2004

A drug database model as a central element for computer-supported dose adjustment within a CPOE system.

The incidence of adverse drug reactions may be decreased by computerized physician order entry (CPOE) with decision support. The authors describe the development of a drug database model for computer-supported dose adjustment within a CPOE system. The following two core elements were included: (1) To allow electronic dose and volume calculation, the relation between strength (e.g., 5 mg/1 mL) and prescribed unit (e.g., 1 ampoule containing 2 mL) must be available in coded form. (2) The site of action along with the parent active ingredient, i.e., the pure drug without salt or ester, is necessary for linkage to knowledge bases. All complex examples of drugs that were examined could be described by the data model. With the ultimate goal of increasing prescribing effectiveness and quality the authors developed a drug database model for inclusion in a CPOE system, which allows dose calculations and may be coupled to decision support systems.

Databases, Factual↗
PubMed2002

Metadata-driven creation of data marts from an EAV-modeled clinical research database.

Generic clinical study data management systems can record data on an arbitrary number of parameters in an arbitrary number of clinical studies without requiring modification of the database schema. They achieve this by using an Entity-Attribute-Value (EAV) model for clinical data. While very flexible for creating transaction-oriented systems for data entry and browsing of individual forms, EAV-modeled data is unsuitable for direct analytical processing, which is the focus of data marts. For this purpose, such data must be extracted and restructured appropriately. This paper describes how such a process, which is non-trivial and highly error prone if performed using non-systematic approaches, can be automated by judicious use of the study metadata-the descriptions of measured parameters and their higher-level grouping. The metadata, in addition to driving the process, is exported along with the data, in order to facilitate its human interpretation.

Breast Neoplasms↗
PubMed2001

Computer assisted oral and maxillofacial surgery--a review and an assessment of technology.

Advances in the basic scientific research within the field of computer assisted oral and maxillofacial surgery have enabled us to introduce features of these techniques into routine clinical practice. In order to simulate complex surgery with the aid of a computer, the diagnostic image data and especially various imaging modalities including computer tomography (CT), magnetic resonance imaging (MRI) and Ultrasound (US) must be arranged in relation to each other, thus enabling a rapid switching between the various modalities as well as the viewing of superimposed images. Segmenting techniques for the reconstruction of three-dimensional representations of soft and hard tissues are required. We must develop ergonomic and user friendly interactive methods for the surgeon, thus allowing for a precise and fast entry of the planned surgical procedure in the planning and simulation phase. 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 and within this article we present a review of the development of this rapidly evolving technique. Future intraoperative assistance takes 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. The techniques of virtual reality and computer assisted surgery are increasingly important in their medical applications. Many applications are still being developed or are still in the form of a prototype. It is already clear, however, that developments in this area will have a considerable effect on a surgeon's routine work.

Computer Simulation↗
PubMed2003

Enabling technologies promise to revitalize the role of nursing in an era of patient safety.

The application of information technology (IT) in health care has the potential to transform the delivery of care, as well as the health care work environment, by streamlining processes, making procedures more accurate and efficient, and reducing the risk of human error. For nurses, a major aspect of this transformation is the refocusing of their work on direct patient care and away from being a conduit of information and communication among departments. Several of the technologies discussed, such as physician order entry and bar code technology, have existed for years as standalone systems. Many others are just being developed and are being integrated into complex clinical information systems (CISs) with clinical decision support at their core. While early evaluation of these systems shows positive outcome measurements, financial, technical, and organizational hurdles to widespread implementation still remain. One major issue is defining the role nurses, themselves, will play in the selection and implementation of these systems as they become more steeped in the knowledge of nursing informatics. Other challenges revolve around issues of job satisfaction and the attraction and retention of nursing staff in the midst of a serious nursing shortage. Despite these concerns, it is expected that, in the long run, the creation of an electronic work environment with systems that integrate all functions of the health care team will positively impact cost-effectiveness, productivity, and patient safety while helping to revitalize nursing practice.

Communication↗
PubMed2003

Improving patient safety across a large integrated health care delivery system.

OBJECTIVE: Patient safety is moving up the list of priorities for hospitals and health care delivery systems, but improving safety across a large organization is challenging. We sought to create a common patient safety strategy for the Partners HealthCare system, a large, integrated, non-profit health care delivery system in the United States. DESIGN: Partners identified a central Patient Safety Officer, who then formed a Patient Safety Advisory Group with local expert members, as well as a Patient Safety Leaders Group comprised of personnel responsible for patient safety at each member institution. The latter group meets monthly to help determine future projects and to share the results of piloting and implementation. There was broad consensus that interventions should include the areas of culture change, process change, and process measurement. SETTING: A large, integrated health care delivery system in the Boston, Massachusetts, area. RESULTS: Key milestones to date include implementation of Executive WalkRounds, development of accountability principles, agreement to create a common system-wide adverse event reporting system, and agreement to implement computerized physician order entry in all hospitals. These efforts have heightened awareness of patient safety considerably within the network. Most influenced to date have been the senior leaders of the hospitals, which has resulted in substantial support for patient safety initiatives. CONCLUSIONS: This loosely integrated delivery system represents a daunting landscape for the development and institution of patient safety concepts. Many projects aimed at different components of patient safety must occur at the same time for significant change, yet culture and care-related beliefs vary substantially within the system, and measurement is especially challenging. Moreover, with many potential interventions, and limited resources, prioritization and selection is difficult. Nonetheless, consensus about some issues has been reached, in particular because of a well delineated patient safety structure. We believe the net result will be substantial improvement in patient safety.

Boston↗