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Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2012年第4期19卷 610-614页

作者： Love, Jennifer S. Wright, Adam Simon, Steven R. Jenter, Chelsea A. Soran, Christine S. Volk, Lynn A. Bates, David W. Poon, Eric G. Partners HealthCare Clin & Qual Anal Informat Syst Boston MA USA Brigham & Womens Hosp Boston MA 02115 USA VA Boston Healthcare Syst Boston MA USA

Background Electronic health record (EHR) adoption is a national priority in the USA, and well-designed EHRs have the potential to improve quality and safety. However, physicians are reluctant to implement EHRs due to financial constraints, usability concerns, and apprehension about unintended consequences, including the introduction of medical errors related to EHR use. The goal of this study was to characterize and describe physicians' attitudes towards three consequences of EHR implementation: (1) the potential for EHRs to introduce new errors;(2) improvements in healthcare quality;and (3) changes in overall physician satisfaction. Methods using data from a 2007 statewide survey of Massachusetts physicians, we conducted multivariate regression analysis to examine relationships between practice characteristics, perceptions of EHR-related errors, perceptions of healthcare quality, and overall physician satisfaction. Results 30% of physicians agreed that EHRs create new opportunities for error, but only 2% believed their EHR has created more errors than it prevented. With respect to perceptions of quality, there was no significant association between perceptions of EHR-associated errors and perceptions of EHR-associated changes in healthcare quality. Finally, physicians who believed that EHRs created new opportunities for error were less likely be satisfied with their practice situation (adjusted OR 0.49, p=0.001). Conclusions Almost one third of physicians perceived that EHRs create new opportunities for error. This perception was associated with lower levels of physician satisfaction.

关键词： Electronic medical records medical errors hospital information systems unintended consequences physician satisfaction electronic health record developing/using computerized provider order entry knowledge representations classical experimental and quasi-experimental study methods (lab and field) designing usable (responsive) resources and systems statistical analysis of large datasets health information technology quality of care electronic health records veterans primary care patient safety decision support data exchange

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Patient characteristics associated with venous thromboembolic events: a cohort study using pooled electronic health record data

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2012年第6期19卷 965-972页

作者： Kaelber, David C. Foster, Wendy Gilder, Jason Love, Thomas E. Jain, Anil K. MetroHlth Syst Dept Informat Serv Cleveland OH USA Case Western Reserve Univ Dept Internal Med Cleveland OH 44106 USA Case Western Reserve Univ Dept Pediat Cleveland OH 44106 USA Case Western Reserve Univ Dept Epidemiol Cleveland OH 44106 USA MetroHlth Syst Ctr Clin Informat Res & Educ Cleveland OH USA Explorys Inc Cleveland OH USA Case Western Reserve Univ Sch Med Dept Med Cleveland OH 44106 USA Case Western Reserve Univ Sch Med Dept Epidemiol Cleveland OH USA Case Western Reserve Univ Ctr Hlth Care Res & Policy MetroHlth Syst Cleveland OH 44106 USA Cleveland Clin Dept Internal Med Cleveland OH 44106 USA Case Western Reserve Univ Sch Med Dept Biostat Cleveland OH USA

Objective To demonstrate the potential of de-identified clinical data from multiple healthcare systems using different electronic health records (EHR) to be efficiently used for very large retrospective cohort studies. Materials and methods Data of 959 030 patients, pooled from multiple different healthcare systems with distinct ERR, were obtained. Data were standardized and normalized using common ontologies, searchable through a HIPAA-compliant, patient de-identified web application (Explore;Explorys Inc). Patients were 26 years or older seen in multiple healthcare systems from 1999 to 2011 with data from EHR. Results Comparing obese, tall subjects with normal body mass index, short subjects, the venous thromboembolic events (VIE) OR was 1.83 (95% CI 1.76 to 1.91) for women and 1.21 (1.10 to 1.32) for men. Weight had more effect then height on VIE. Compared with Caucasian, Hispanic/Latino subjects had a much lower risk of VIE (female OR 0.47, 0.41 to 0.55;male OR 0.24, 0.20 to 0.28) and African-Americans a substantially higher risk (female OR 1.83, 1.76 to 1.91;male OR 1.58, 1.50 to 1.66). This 13-year retrospective study of almost one million patients was performed over approximately 125 h in 11 weeks, part time by the five authors. Discussion As research informatics tools develop and more clinical data become available in ERR, it is important to study and understand unique opportunities for clinical research informatics to transform the scale and resources needed to perform certain types of clinical research. Conclusions With the right clinical research informatics tools and EHR data, some types of very large cohort studies can be completed with minimal resources.

关键词： Clinical informatics demonstrating return on IT investment developing/using clinical decision support (other than diagnostic) and guideline systems developing/using computerized provider order entry enhancing the conduct of biological/clinical research and trials methods for integration of information from disparate sources monitoring the health of populations personal health records and self-care systems

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The Hub Population Health System: distributed ad hoc queries and alerts

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2012年第E1期19卷 E46-E50页

作者： Buck, Michael D. Anane, Sheila Taverna, John Amirfar, Sam Stubbs-Dame, Remle Singer, Jesse New York City Dept Hlth & Mental Hyg Bur Primary Care Informat Project Queens NY 11101 USA Columbia Univ Dept Biomed Informat New York NY USA

The Hub Population Health System enables the creation and distribution of queries for aggregate count information, clinical decision support alerts at the point-of-care for patients who meet specified conditions, and secure messages sent directly to provider electronic health record (EHR) inboxes. using a metronidazole medication recall, the New York City Department of Health was able to determine the number of affected patients and message providers, and distribute an alert to participating practices. As of September 2011, the system is live in 400 practices and within a year will have over 532 practices with 2500 providers, representing over 2.5 million New Yorkers. The Hub can help public health experts to evaluate population health and quality improvement activities throughout the ambulatory care network. Multiple EHR vendors are building these features in partnership with the department's regional extension center in anticipation of new meaningful use requirements.

关键词： Decision support systems clinical public health informatics population surveillance electronic health records medical informatics developing/using computerized provider order entry methods for integration of information from disparate sources distributed systems agents software engineering: architecture PCIP ambulatory care new york city cardiovascular disease food environment population health

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using the time and motion method to study clinical work processes and workflow: methodological inconsistencies and a call for standardized research

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2011年第5期18卷 704-710页

作者： Zheng, Kai Guo, Michael H. Hanauer, David A. Univ Michigan Sch Publ Hlth Dept Hlth Management & Policy Ann Arbor MI 48109 USA Univ Michigan Sch Informat Ann Arbor MI 48109 USA Univ Florida Coll Med Gainesville FL USA Univ Michigan Dept Pediat Ann Arbor MI 48109 USA Univ Michigan Ctr Comprehens Canc Ann Arbor MI 48109 USA

Objective To identify ways for improving the consistency of design, conduct, and results reporting of time and motion (TEM) research in health informatics. Materials and methods We analyzed the commonalities and divergences of empirical studies published 1990-2010 that have applied the T&M approach to examine the impact of health IT implementation on clinical work processes and workflow. The analysis led to the development of a suggested 'checklist' intended to help future T&M research produce compatible and comparable results. We call this checklist STAMP (Suggested Time And Motion Procedures). Results STAMP outlines a minimum set of 29 data/information elements organized into eight key areas, plus three supplemental elements contained in an 'Ancillary Data' area, that researchers may consider collecting and reporting in their future T&M endeavors. Discussion TEM is generally regarded as the most reliable approach for assessing the impact of health IT implementation on clinical work. However, there exist considerable inconsistencies in how previous TEN studies were conducted and/or how their results were reported, many of which do not seem necessary yet can have a significant impact on quality of research and generalisability of results. Therefore, we deem it is time to call for standards that can help improve the consistency of TEN research in health informatics. This study represents an initial attempt. Conclusion We developed a suggested checklist to improve the methodological and results reporting consistency of T&M research, so that meaningful insights can be derived from across-study synthesis and health informatics, as a field, will be able to accumulate knowledge from these studies.

关键词： Time and motion studies (F02.784.412.846.707) workflow (L01.906.893) health information technology (L01.700) medical informatics applications (L01.700.508) collaborative technologies personal health records and self-care systems developing/using clinical decision support (other than diagnostic) and guideline systems systems supporting patient-provider interaction human-computer interaction and human-centered computing improving healthcare workflow and process efficiency system implementation and management issues social/organizational study qualitative/ethnographic field study cognitive study (including experiments emphasizing verbal protocol analysis and usability) methods for integration of information from disparate sources information storage and retrieval (text and images) data exchange communication integration across care settings (inter- and intra-enterprise) visualization of data and knowledge developing/using computerized provider order entry

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Handling anticipated exceptions in clinical care: investigating clinician use of 'exit strategies' in an electronic health records system

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2011年第6期18卷 883-889页

作者： Zheng, Kai Hanauer, David A. Padman, Rema Johnson, Michael P. Hussain, Anwar A. Ye, Wen Zhou, Xiaomu Diamond, Herbert S. Univ Michigan Sch Informat Dept Hlth Management & Policy Sch Publ Hlth Ann Arbor MI 48109 USA Univ Michigan Dept Pediat Ann Arbor MI 48109 USA Carnegie Mellon Univ H John Heinz Coll 3 Pittsburgh PA 15213 USA Univ Massachusetts Dept Publ Policy & Publ Affairs John W McCormack Grad Sch Policy Studies Boston MA 02125 USA United Hlth Serv Hosp Johnson City NY USA Univ Michigan Sch Publ Hlth Dept Biostat Ann Arbor MI 48109 USA Rutgers State Univ Sch Commun & Informat New Brunswick NJ 08903 USA Univ Pittsburgh Sch Med Dept Med Div Rheumatol Pittsburgh PA USA

Unpredictable yet frequently occurring exception situations pervade clinical care. Handling them properly often requires aberrant actions temporarily departing from normal practice. In this study, the authors investigated several exception-handling procedures provided in an electronic health records system for facilitating clinical documentation, which the authors refer to as 'data entry exit strategies.' Through a longitudinal analysis of computer-recorded usage data, the authors found that (1) utilization of the exit strategies was not affected by postimplementation system maturity or patient visit volume, suggesting clinicians' needs to 'exit' unwanted situations are persistent;and (2) clinician type and gender are strong predictors of exit-strategy usage. Drilldown analyses further revealed that the exit strategies were judiciously used and enabled actions that would be otherwise difficult or impossible. However, many data entries recorded via them could have been 'properly' documented, yet were not, and a considerable proportion containing temporary or incomplete information was never subsequently amended. These findings may have significant implications for the design of safer and more user-friendly point-of-care information systems for healthcare.

关键词： Electronic health records (E05.318.308.940.968.625.500) workflow (L01.906.893) documentation (L01.453.245) exit strategy exception-handling collaborative technologies personal health records and self-care systems developing/using clinical decision support (other than diagnostic) and guideline systems systems supporting patient–provider interaction human–computer interaction and human-centered computing improving healthcare workflow and process efficiency system implementation and management issues social/organizational study qualitative/ethnographic field study cognitive study (including experiments emphasizing verbal protocol analysis and usability) methods for integration of information from disparate sources information storage and retrieval (text and images) data exchange communication and integration across care settings (inter- and intraenterprise) visualization of data and knowledge developing/using computerized provider order entry diamond

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Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2011年第3期18卷 232-242页

作者： Wright, Adam Sittig, Dean F. Ash, Joan S. Feblowitz, Joshua Meltzer, Seth McMullen, Carmit Guappone, Ken Carpenter, Jim Richardson, Joshua Simonaitis, Linas Evans, R. Scott Nichol, W. Paul Middleton, Blackford Brigham & Womens Hosp Div Gen Med & Primary Care Boston MA 02115 USA Partners HealthCare Boston MA USA Harvard Univ Sch Med Boston MA USA Univ Texas Houston UT Mem Hermann Ctr Healthcare Qual & Safety Sch Biomed Informat Houston TX USA Oregon Hlth & Sci Univ Dept Med Informat & Clin Epidemiol Portland OR 97201 USA Kaiser Permanente Ctr Hlth Res Portland OR USA Providence Portland Med Ctr Reg Informat Serv Portland OR USA Weill Cornell Med Coll Ctr Healthcare Informat & Policy New York NY USA Indiana Univ Sch Med Regenstrief Inst Inc Indianapolis IN USA Intermt Hlth Care Dept Med Informat Salt Lake City UT USA Vet Hlth Adm Patient Care Serv Seattle WA USA

Background Clinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited research on the availability of various CDS tools across current electronic health record (EHR) systems. Objective To develop and validate a taxonomy of front-end CDS tools and to assess support for these tools in major commercial and internally developed EHRs. Study design and methods We used a modified Delphi approach with a panel of 11 decision support experts to develop a taxonomy of 53 front-end CDS tools. Based on this taxonomy, a survey on CDS tools was sent to a purposive sample of commercial EHR vendors (n=9) and leading healthcare institutions with internally developed state-of-the-art EHRs (n=4). Results Responses were received from all healthcare institutions and 7 of 9 EHR vendors (response rate: 85%). All 53 types of CDS tools identified in the taxonomy were found in at least one surveyed EHR system, but only 8 functions were present in all EHRs. Medication dosing support and order facilitators were the most commonly available classes of decision support, while expert systems (eg, diagnostic decision support, ventilator management suggestions) were the least common. Conclusion We developed and validated a comprehensive taxonomy of front-end CDS tools. A subsequent survey of commercial EHR vendors and leading healthcare institutions revealed a small core set of common CDS tools, but identified significant variability in the remainder of clinical decision support content.

关键词： developing/using computerized provider order entry knowledge representations classical experimental and quasi-experimental study methods (lab and field) designing usable (responsive) resources and systems statistical analysis of large datasets discovery text and data mining methods automated learning human-computer interaction and human-centered computing qualitative/ethnographic field study clinical decision support manning maddux decision support biomedical informatics developing and refining EHR data standards (including image standards) controlled terminologies and vocabularies measuring/improving patient safety and reducing medical errors machine learning electronic health records meaningful use

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Collaborative search in electronic health records

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2011年第3期18卷 282-291页

作者： Zheng, Kai Mei, Qiaozhu Hanauer, David A. Univ Michigan Sch Publ Hlth Dept Hlth Management & Policy Sch Informat Ann Arbor MI 48109 USA Univ Michigan Dept Elect Engn & Comp Sci Ann Arbor MI 48109 USA Univ Michigan Dept Pediat Ann Arbor MI 48109 USA Univ Michigan Ctr Comprehens Canc Ann Arbor MI 48109 USA

Objective A full-text search engine can be a useful tool for augmenting the reuse value of unstructured narrative data stored in electronic health records (EHR). A prominent barrier to the effective utilization of such tools originates from users' lack of search expertise and/or medical-domain knowledge. To mitigate the issue, the authors experimented with a 'collaborative search' feature through a homegrown EHR search engine that allows users to preserve their search knowledge and share it with others. This feature was inspired by the success of many social information-foraging techniques used on the web that leverage users' collective wisdom to improve the quality and efficiency of information retrieval. Design The authors conducted an empirical evaluation study over a 4-year period. The user sample consisted of 451 academic researchers, medical practitioners, and hospital administrators. The data were analyzed using a social-network analysis to delineate the structure of the user collaboration networks that mediated the diffusion of knowledge of search. Results The users embraced the concept with considerable enthusiasm. About half of the EHR searches processed by the system (0.44 million) were based on stored search knowledge;0.16 million utilized shared knowledge made available by other users. The social-network analysis results also suggest that the user-collaboration networks engendered by the collaborative search feature played an instrumental role in enabling the transfer of search knowledge across people and domains. Conclusion Applying collaborative search, a social information-foraging technique popularly used on the web, may provide the potential to improve the quality and efficiency of information retrieval in healthcare.

关键词： Collaborative technologies personal health records and self-care systems developing/using clinical decision support (other than diagnostic) and guideline systems systems supporting patient-provider interaction human–computer interaction and human-centered computing improving healthcare workflow and process efficiency system implementation and management issues social/organizational study qualitative/ethnographic field study cognitive study (including experiments emphasizing verbal protocol analysis and usability) methods for integration of information from disparate sources information storage and retrieval (text and images) data exchange communication integration across care settings (inter- and intraenterprise) visualization of data and knowledge developing/using computerized provider order entry

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Normalized names for clinical drugs: RxNorm at 6 years

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2011年第4期18卷 441-448页

作者： Nelson, Stuart J. Zeng, Kelly Kilbourne, John Powell, Tammy Moore, Robin NIH US Natl Lib Med Bethesda MD 20892 USA

Objective In the 6 years since the National Library of Medicine began monthly releases of RxNorm, RxNorm has become a central resource for communicating about clinical drugs and supporting interoperation between drug vocabularies. Materials and methods Built on the idea of a normalized name for a medication at a given level of abstraction, RxNorm provides a set of names and relationships based on 11 different external source vocabularies. The standard model enables decision support to take place for a variety of uses at the appropriate level of abstraction. With the incorporation of National Drug File Reference Terminology (NDF-RT) from the Veterans Administration, even more sophisticated decision support has become possible. Discussion While related products such as RxTerms, RxNav, MyMedicationList, and MyRxPad have been recognized as helpful for various uses, tasks such as identifying exactly what is and is not on the market remain a challenge.

关键词： Ontologies knowledge representations natural-language processing information storage and retrieval (text and images) data models developing/using computerized provider order entry personal health records and self-care systems developing/using clinical decision support (other than diagnostic) and guideline systems systems to support and improve diagnostic accuracy distributed systems agents software engineering: architecture developing and refining EHR Data standards (including image standards) controlled terminologies and vocabularies

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Clinical decision support in small community practice settings: a case study

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2011年第6期18卷 879-882页

作者： Ash, Joan S. Sittig, Dean F. Wright, Adam McMullen, Carmit Shapiro, Michael Bunce, Arwen Middleton, Blackford Oregon Hlth & Sci Univ Portland OR 97201 USA Univ Texas Hlth Sci Ctr Houston TX USA Brigham & Womens Hosp Boston MA 02115 USA Harvard Univ Sch Med Boston MA USA Partners HealthCare Boston MA USA Kaiser Permanente Ctr Hlth Res Portland OR USA

using an eight-dimensional model for studying socio-technical systems, a multidisciplinary team of investigators identified barriers and facilitators to clinical decision support (CDS) implementation in a community setting, the Mid-Valley Independent Physicians Association in the Salem, Oregon area. The team used the Rapid Assessment Process, which included nine formal interviews with CDS stakeholders, and observation of 27 clinicians. The research team, which has studied 21 healthcare sites of various sizes over the past 12 years, believes this site is an excellent example of an organization which is using a commercially available electronic-health-record system with CDS well. The eight-dimensional model proved useful as an organizing structure for the evaluation.

关键词： developing/using computerized provider order entry improving the education and skills training of health professionals developing/using clinical decision support (other than diagnostic) and guideline systems social/organizational study qualitative/ethnographic field study knowledge representations classical experimental and quasi-experimental study methods (lab and field) designing usable (responsive) resources and systems statistical analysis of large datasets discovery and text and data mining methods automated learning human–computer interaction and human-centered computing qualitative/ethnographic field study clincal decision support machine learning knowledge bases clinical decision support ambulatory care ambulatory care

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A multi-layered framework for disseminating knowledge for computer-based decision support

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2011年第SUPPLEMENT_1期18卷 I132-I139页

作者： Boxwala, Aziz A. Rocha, Beatriz H. Maviglia, Saverio Kashyap, Vipul Meltzer, Seth Kim, Jihoon Tsurikova, Ruslana Wright, Adam Paterno, Marilyn D. Fairbanks, Amanda Middleton, Blackford Univ Calif San Diego Sch Med Div Biomed Informat Dept Med La Jolla CA 92093 USA Brigham & Womens Hosp Boston MA 02115 USA Harvard Univ Sch Med Dept Med Boston MA USA Cigna Healthcare Hartford CT USA

Background 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. Methods 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. Conclusion 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.

关键词： Knowledge bases Translational research - application of biological knowledge to clinical care developing/using clinical decision support (other than diagnostic) and guideline systems knowledge acquisition and knowledge management clinical informatics clinical decision support semantic web Manning Maddux bioinformatics datamining predictive modeling developing/using computerized provider order entry knowledge representations classical experimental and quasi-experimental study methods (lab and field) designing usable (responsive) resources and systems statistical analysis of large datasets visualization of data and knowledge knowledge representations knowledge acquisition and knowledge management distributed systems agents software engineering: architecture developing and refining ehr data standards (including image standards) data models data exchange controlled terminologies and vocabularies communication and integration across care settings (inter- and intra-enterprise) knowledge bases knowledge representations uncertain reasoning and decision theory designing usable (responsive) resources and systems personal health records and self-care systems knowledge acquisition and knowledge management demonstrating return on it investment other specific ehr applications (results review medication administration disease progression

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