Hypertension is the most prevalent chronic condition diagnosed among patients served in the safety net in the United States; however, many safety-net patients with hypertension are not formally ...diagnosed and may remain untreated and at increased risk for cardiovascular events. Identifying undiagnosed hypertension using algorithmic logic programmed into clinical decision support (CDS) approaches is a promising practice but has not been broadly tested in the safety-net setting.
The project used a quality improvement approach wherein information flows and actions related to blood pressure measurement were modified to include algorithm criteria to identify patients who might have undiagnosed hypertension. Identified patients were recalled for evaluation and hypertension diagnosis, if appropriate. Ten health centers in Arkansas, California, Kentucky, and Missouri were selected to participate in the project on the basis of high hypertension prevalence (compared to national average), demographic and geographic diversity, mature information systems infrastructure, and executive support. The project targeted patients from 18 to 85 years of age.
After implementation of algorithm-based interventions, diagnosed hypertension prevalence increased significantly from 34.5% to 36.7% (p < 0.05). A cohort of patients was tracked from 8 of the 10 health centers to assess follow-up evaluation and diagnosis rates; 65.2% completed a follow-up evaluation, of which 31.9% received a hypertension diagnosis.
Using algorithmic logic and other CDS–enabled care process improvements appears to be an effective way health centers can identify and engage patients at risk for undiagnosed hypertension. Appropriately diagnosing all hypertensive patients ensures that hypertension control efforts yield maximal improvements in population health.
A roadmap for national action on clinical decision support Osheroff, Jerome A; Teich, Jonathan M; Middleton, Blackford ...
Journal of the American Medical Informatics Association : JAMIA,
03/2007, Letnik:
14, Številka:
2
Journal Article
Recenzirano
Odprti dostop
This document comprises an AMIA Board of Directors approved White Paper that presents a roadmap for national action on clinical decision support. It is published in JAMIA for archival and ...dissemination purposes. The full text of this material has been previously published on the AMIA Web site (www.amia.org/inside/initiatives/cds). AMIA is the copyright holder.
Grand challenges in clinical decision support Sittig, Dean F.; Wright, Adam; Osheroff, Jerome A. ...
Journal of biomedical informatics,
04/2008, Letnik:
41, Številka:
2
Journal Article
Recenzirano
Odprti dostop
There is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and maintaining all types of clinical decision support capabilities for ...clinicians, patients and consumers. Using an iterative, consensus-building process we identified a rank-ordered list of the top 10 grand challenges in clinical decision support. This list was created to educate and inspire researchers, developers, funders, and policy-makers. The list of challenges in order of importance that they be solved if patients and organizations are to begin realizing the fullest benefits possible of these systems consists of: improve the human–computer interface; disseminate best practices in CDS design, development, and implementation; summarize patient-level information; prioritize and filter recommendations to the user; create an architecture for sharing executable CDS modules and services; combine recommendations for patients with co-morbidities; prioritize CDS content development and implementation; create internet-accessible clinical decision support repositories; use freetext information to drive clinical decision support; mine large clinical databases to create new CDS. Identification of solutions to these challenges is critical if clinical decision support is to achieve its potential and improve the quality, safety and efficiency of healthcare.
Venous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices ...for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes. The SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE.sup.2-AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a "Living Guideline" process model for the VTE prevention CDS system. The stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics.
To identify the most frequent obstacles preventing physicians from answering their patient-care questions and the most requested improvements to clinical information resources.
Qualitative analysis ...of questions asked by 48 randomly selected generalist physicians during ambulatory care.
Frequency of reported obstacles to answering patient-care questions and recommendations from physicians for improving clinical information resources.
The physicians asked 1,062 questions but pursued answers to only 585 (55%). The most commonly reported obstacle to the pursuit of an answer was the physician's doubt that an answer existed (52 questions, 11%). Among pursued questions, the most common obstacle was the failure of the selected resource to provide an answer (153 questions, 26%). During audiotaped interviews, physicians made 80 recommendations for improving clinical information resources. For example, they requested comprehensive resources that answer questions likely to occur in practice with emphasis on treatment and bottom-line advice. They asked for help in locating information quickly by using lists, tables, bolded subheadings, and algorithms and by avoiding lengthy, uninterrupted prose.
Physicians do not seek answers to many of their questions, often suspecting a lack of usable information. When they do seek answers, they often cannot find the information they need. Clinical resource developers could use the recommendations made by practicing physicians to provide resources that are more useful for answering clinical questions.
Advances in technology and the scientific understanding of disease processes are presenting new opportunities to improve health through individualized approaches to patient management referred to as ...personalized medicine. Future health care strategies that deploy genomic technologies and molecular therapies will bring opportunities to prevent, predict, and pre-empt disease processes but will be dependent on knowledge management capabilities for health care providers that are not currently available. A key cornerstone to the potential application of this knowledge will be effective use of electronic health records. In particular, appropriate clinical use of genomic test results and molecularly-targeted therapies present important challenges in patient management that can be effectively addressed using electronic clinical decision support technologies.
Approaches to shaping future health information needs for personalized medicine were undertaken by a work group of the American Health Information Community. A needs assessment for clinical decision support in electronic health record systems to support personalized medical practices was conducted to guide health future development activities. Further, a suggested action plan was developed for government, researchers and research institutions, developers of electronic information tools (including clinical guidelines, and quality measures), and standards development organizations to meet the needs for personalized approaches to medical practice. In this article, we focus these activities on stakeholder organizations as an operational framework to help identify and coordinate needs and opportunities for clinical decision support tools to enable personalized medicine.
This perspective addresses conceptual approaches that can be undertaken to develop and apply clinical decision support in electronic health record systems to achieve personalized medical care. In addition, to represent meaningful benefits to personalized decision-making, a comparison of current and future applications of clinical decision support to enable individualized medical treatment plans is presented. If clinical decision support tools are to impact outcomes in a clear and positive manner, their development and deployment must therefore consider the needs of the providers, including specific practice needs, information workflow, and practice environment.
Abstract Objective: To describe the obstacles encountered when attempting to answer doctors' questions with evidence. Design: Qualitative study. Setting: General practices in Iowa. Participants: 9 ...academic generalist doctors, 14 family doctors, and 2 medical librarians. Main outcome measure: A taxonomy of obstacles encountered while searching for evidence based answers to doctors' questions. Results: 59 obstacles were encountered and organised according to the five steps in asking and answering questions: recognise a gap in knowledge, formulate a question, search for relevant information, formulate an answer, and use the answer to direct patient care. Six obstacles were considered particularly salient by the investigators and practising doctors: the excessive time required to find information; difficulty modifying the original question, which was often vague and open to interpretation; difficulty selecting an optimal strategy to search for information; failure of a seemingly appropriate resource to cover the topic; uncertainty about how to know when all the relevant evidence has been found so that the search can stop; and inadequate synthesis of multiple bits of evidence into a clinically useful statement. Conclusions: Many obstacles are encountered when asking and answering questions about how to care for patients. Addressing these obstacles could lead to better patient care by improving clinically oriented information resources. What is already known on this topic Doctors are encouraged to search for evidence based answers to their questions about patient care but most go unanswered Studies have not defined the obstacles to answering questions in a systematic manner A comprehensive description of such obstacles has not been presented What this study adds Fifty nine obstacles were found while attempting to answer clinical questions with evidence; six were particularly salient The obstacles were comprehensively described and organised
Approach to leg edema of unclear etiology Ely, John W; Osheroff, Jerome A; Chambliss, M Lee ...
Journal of the American Board of Family Medicine,
03/2006, Letnik:
19, Številka:
2
Journal Article
Recenzirano
Odprti dostop
A common challenge for primary care physicians is to determine the cause and find an effective treatment for leg edema of unclear etiology. We were unable to find existing practice guidelines that ...address this problem in a comprehensive manner. This article provides clinically oriented recommendations for the management of leg edema in adults. We searched on-line resources, textbooks, and MEDLINE (using the MeSH term, "edema") to find clinically relevant articles on leg edema. We then expanded the search by reviewing articles cited in the initial sources. Our goal was to write a brief, focused review that would answer questions about the management of leg edema. We organized the information to make it rapidly accessible to busy clinicians. The most common cause of leg edema in older adults is venous insufficiency. The most common cause in women between menarche and menopause is idiopathic edema, formerly known as "cyclic" edema. A common but under-recognized cause of edema is pulmonary hypertension, which is often associated with sleep apnea. Venous insufficiency is treated with leg elevation, compressive stockings, and sometimes diuretics. The initial treatment of idiopathic edema is spironolactone. Patients who have findings consistent with sleep apnea, such as daytime somnolence, loud corrected snoring, or neck circumference >17 inches, should be evaluated for pulmonary hypertension with an echocardiogram. If time is limited, the physician must decide whether the evaluation can be delayed until a later appointment (eg, an asymptomatic patient with chronic bilateral edema) or must be completed at the current visit (eg, a patient with dyspnea or a patient with acute edema <72 hours). If the evaluation should be conducted at the current visit, the algorithm shown in Figure 1 could be used as a guide. If the full evaluation could wait for a subsequent visit, the patient should be examined briefly to rule out an obvious systemic cause and basic laboratory tests should be ordered for later review (complete blood count, urinalysis, electrolytes, creatinine, blood sugar, thyroid stimulating hormone, and albumin).
Clinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits have ...not been fully realized. In this consensus white paper, we set forth recommendations and action plans in three critical domains: (1) advances in system capabilities, including basic and advanced sets of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption.
PDF
