There are several challenges in encoding guideline knowledge in a form that is portable to different clinical sites, including the heterogeneity of clinical decision support (CDS) tools, of patient ...data representations, and of workflows.
We have developed a multi-layered knowledge representation framework for structuring guideline recommendations for implementation in a variety of CDS contexts. In this framework, guideline recommendations are increasingly structured through four layers, successively transforming a narrative text recommendation into input for a CDS system. We have used this framework to implement rules for a CDS service based on three guidelines. We also conducted a preliminary evaluation, where we asked CDS experts at four institutions to rate the implementability of six recommendations from the three guidelines.
The experience in using the framework and the preliminary evaluation indicate that this approach has promise in creating structured knowledge, to implement in CDS systems, that is usable across organizations.
This study sought to develop a functional taxonomy of rule-based clinical decision support.
The rule-based clinical decision support content of a large integrated delivery network with a long history ...of computer-based point-of-care decision support was reviewed and analyzed along four functional dimensions: trigger, input data elements, interventions, and offered choices.
A total of 181 rule types were reviewed, comprising 7,120 different instances of rule usage. A total of 42 taxa were identified across the four categories. Many rules fell into multiple taxa in a given category. Entered order and stored laboratory result were the most common triggers; laboratory result, drug list, and hospital unit were the most frequent data elements used. Notify and log were the most common interventions, and write order, defer warning, and override rule were the most common offered choices.
A relatively small number of taxa successfully described a large body of clinical knowledge. These taxa can be directly mapped to functions of clinical systems and decision support systems, providing feature guidance for developers, implementers, and certifiers of clinical information systems.
In this paper we assess the value of electronic health care information exchange and interoperability (HIEI) between providers (hospitals and medical group practices) and independent laboratories, ...radiology centers, pharmacies, payers, public health departments, and other providers. We have created an HIEI taxonomy and combined published evidence with expert opinion in a cost-benefit model. Fully standardized HIEI could yield a net value of $77.8 billion per year once fully implemented. Nonstandardized HIEI offers smaller positive financial returns. The clinical impact of HIEI for which quantitative estimates cannot yet be made would likely add further value. A compelling business case exists for national implementation of fully standardized HIEI.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
44.
Putting the 'i' in iHealth Middleton, Blackford; Fickenscher, Kevin M
Journal of the American Medical Informatics Association : JAMIA,
2014 Jan-Feb, 2014-01-00, 20140101, Letnik:
21, Številka:
1
Journal Article
Although computerized physician order entry (CPOE) may decrease errors and improve quality, hospital adoption has been slow. The high costs and limited data on financial benefits of CPOE systems are ...a major barrier to adoption. The authors assessed the costs and financial benefits of the CPOE system at Brigham and Women's Hospital over ten years.
Cost and benefit estimates of a hospital CPOE system at Brigham and Women's Hospital (BWH), a 720-adult bed, tertiary care, academic hospital in Boston.
Institutional experts provided data about the costs of the CPOE system. Benefits were determined from published studies of the BWH CPOE system, interviews with hospital experts, and relevant internal documents. Net overall savings to the institution and operating budget savings were determined. All data are presented as value figures represented in 2002 dollars.
Between 1993 and 2002, the BWH spent $11.8 million to develop, implement, and operate CPOE. Over ten years, the system saved BWH $28.5 million for cumulative net savings of $16.7 million and net operating budget savings of $9.5 million given the institutional 80% prospective reimbursement rate. The CPOE system elements that resulted in the greatest cumulative savings were renal dosing guidance, nursing time utilization, specific drug guidance, and adverse drug event prevention. The CPOE system at BWH has resulted in substantial savings, including operating budget savings, to the institution over ten years.
Other hospitals may be able to save money and improve patient safety by investing in CPOE systems.
To describe the activities performed by people involved in clinical decision support (CDS) at leading sites.
We conducted ethnographic observations at seven diverse sites with a history of excellence ...in CDS using the Rapid Assessment Process and analyzed the data using a series of card sorts, informed by Linstone's Multiple Perspectives Model.
We identified 18 activities and grouped them into four areas. Area 1: Fostering relationships across the organization, with activities (a) training and support, (b) visibility/presence on the floor, (c) liaising between people, (d) administration and leadership, (e) project management, (f) cheerleading/buy-in/sponsorship, (g) preparing for CDS implementation. Area 2: Assembling the system with activities (a) providing technical support, (b) CDS content development, (c) purchasing products from vendors (d) knowledge management, (e) system integration. Area 3: Using CDS to achieve the organization's goals with activities (a) reporting, (b) requirements-gathering/specifications, (c) monitoring CDS, (d) linking CDS to goals, (e) managing data. Area 4: Participation in external policy and standards activities (this area consists of only a single activity). We also identified a set of recommendations associated with these 18 activities.
All 18 activities we identified were performed at all sites, although the way they were organized into roles differed substantially. We consider these activities critical to the success of a CDS program.
A series of activities are performed by sites strong in CDS, and sites adopting CDS should ensure they incorporate these activities into their efforts.
Allergy documentation and exchange are vital to ensuring patient safety. This study aims to analyze and compare various existing standard terminologies for representing allergy information.
Five ...terminologies were identified, including the Systemized Nomenclature of Medical Clinical Terms (SNOMED CT), National Drug File-Reference Terminology (NDF-RT), Medication Dictionary for Regulatory Activities (MedDRA), Unique Ingredient Identifier (UNII), and RxNorm. A qualitative analysis was conducted to compare desirable characteristics of each terminology, including content coverage, concept orientation, formal definitions, multiple granularities, vocabulary structure, subset capability, and maintainability. A quantitative analysis was also performed to compare the content coverage of each terminology for (1) common food, drug, and environmental allergens and (2) descriptive concepts for common drug allergies, adverse reactions (AR), and no known allergies.
Our qualitative results show that SNOMED CT fulfilled the greatest number of desirable characteristics, followed by NDF-RT, RxNorm, UNII, and MedDRA. Our quantitative results demonstrate that RxNorm had the highest concept coverage for representing drug allergens, followed by UNII, SNOMED CT, NDF-RT, and MedDRA. For food and environmental allergens, UNII demonstrated the highest concept coverage, followed by SNOMED CT. For representing descriptive allergy concepts and adverse reactions, SNOMED CT and NDF-RT showed the highest coverage. Only SNOMED CT was capable of representing unique concepts for encoding no known allergies.
The proper terminology for encoding a patient's allergy is complex, as multiple elements need to be captured to form a fully structured clinical finding. Our results suggest that while gaps still exist, a combination of SNOMED CT and RxNorm can satisfy most criteria for encoding common allergies and provide sufficient content coverage.
The exponential growth of biomedical knowledge in computable formats challenges organizations to consider mobilizing artifacts in findable, accessible, interoperable, reusable, and trustable (FAIR+T) ...ways1. There is a growing need to apply biomedical knowledge artifacts to improve health in Learning Health Systems, health delivery organizations, and other settings. However, most organizations lack the infrastructure required to consume and apply computable knowledge, and national policies and standards adoption are insufficient to ensure that it is discoverable and used safely and fairly, nor is there widespread experience in the process of knowledge implementation as clinical decision support. The Mobilizing Computable Biomedical Knowledge (MCBK) community formed in 2016 to address these needs. This report summarizes the main outputs of the Fourth Annual MCBK public meeting, which was held virtually July 20 to July 21, 2021 and convened over 100 participants spanning diverse domains to frame and address important dimensions for mobilizing CBK.
BACKGROUND
Provider and patient reminders can be effective in increasing rates of preventive screenings and vaccinations. However, the effect of patient-directed electronic reminders is understudied.
...OBJECTIVE
To determine whether providing reminders directly to patients via an electronic Personal Health Record (PHR) improved adherence to care recommendations.
DESIGN
We conducted a cluster randomized trial without blinding from 2005 to 2007 at 11 primary care practices in the Partners HealthCare system.
PARTICIPANTS
A total of 21,533 patients with access to a PHR were invited to the study, and 3,979 (18.5%) consented to enroll.
INTERVENTIONS
Patients in the intervention arm received health maintenance (HM) reminders via a secure PHR “eJournal,” which allowed them to review and update HM and family history information. Patients in the active control arm received access to an eJournal that allowed them to input and review information related to medications, allergies and diabetes management.
MAIN MEASURES
The primary outcome measure was adherence to guideline-based care recommendations.
KEY RESULTS
Intention-to-treat analysis showed that patients in the intervention arm were significantly more likely to receive mammography (48.6% vs 29.5%, p = 0.006) and influenza vaccinations (22.0% vs 14.0%, p = 0.018). No significant improvement was observed in rates of other screenings. Although Pap smear completion rates were higher in the intervention arm (41.0% vs 10.4%, p < 0.001), this finding was no longer significant after excluding women’s health clinics. Additional on-treatment analysis showed significant increases in mammography (p = 0.019) and influenza vaccination (p = 0.015) for intervention arm patients who opened an eJournal compared to control arm patients, but no differences for any measure among patients who did not open an eJournal.
CONCLUSIONS
Providing patients with HM reminders via a PHR may be effective in improving some elements of preventive care.
To determine the validity of an electronic health record (EHR) in the identification of patients with left ventricular dysfunction in a primary care setting.
A cross-sectional study.
Nine clinics ...participating from the Providence Research Network (PRN) comprising 75 physicians serving approximately 200,000 patients. All clinics utilise the Logician EHR for all patient care activities.
The study included all PRN patients with an active chart.
All patients with a heart failure diagnosis in the problem list were identified by database query. Left ventricular ejection fraction (LVEF) data were identified through query of local cardiology and hospital echocardiography databases. Additional LVEF data were sought in a manual search of paper charts.
To determine the problem list coding accuracy for a heart failure (HF) diagnosis we evaluated sensitivity, positive predictive value and related derived statistical measures using documented LVEF as the 'gold standard'. Of 205 755 active PRN patients, 1731 were identified with a problem list entry of HF. Based on comparison with documented LVEF, the sensitivity for problem list entry was 43.9% and 54.4% when HF was defined as an LVEF < or = 55% and < or = 40%, respectively.
The validity of an EHR problem list entry of HF was poor. The problem list validity could be enhanced through reconciliation with other data sources. Inaccurate EHR problem lists may have clinical consequences, including underprescribing of beneficial therapies.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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