Adil Ahmed

The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance*

Objectives:The care of critically ill patients generates large quantities of data. Increasingly, these data are presented to the provider within an electronic medical record. The manner in which data are organized and presented can impact on the ability of users to synthesis that data into meaningful information. The objective of this study was to test the hypothesis that novel user interfaces, which prioritize the display of high-value data to providers within system-based packages, reduce task load, and result in fewer errors of cognition compared with established user interfaces that do not. Design:Randomized crossover study. Setting:Academic tertiary referral center. Subjects:Attending, resident and fellow critical care physicians. Interventions:Novel health care record user interface. Measurement:Subjects randomly assigned to either a standard electronic medical record or a novel user interface, were asked to perform a structured task. The task required the subjects to use the assigned electronic environment to review the medical record of an intensive care unit patient said to be actively bleeding for data that formed the basis of answers to clinical questions posed in the form of a structured questionnaire. The primary outcome was task load, measured using the paper version of the NASA-task load index. Secondary outcome measures included time to task completion, number of errors of cognition measured by comparison of subject to post hoc gold standard questionnaire responses, and the quantity of information presented to subjects by each environment. Main Results:Twenty subjects completed the task on eight patients, resulting in 160 patient–provider encounters (80 in each group). The standard electronic medical record contained a much larger data volume with a median (interquartile range) number of data points per patient of 1008 (895–1183) compared with 102 (77–112) contained within the novel user interface. The median (interquartile range) NASA-task load index values were 38.8 (32–45) and 58 (45–65) for the novel user interface compared with the standard electronic medical record (p < .001). The median (interquartile range) times in seconds taken to complete the task for four consecutive patients were 93 (57–132), 60 (48–71), 68 (48–80), and 54 (42–64) for the novel user interface compared with 145 (109–201), 125 (113–162), 129 (100–145), and 112 (92–123) for the standard interface (p < .0001), respectively. The median (interquartile range) number of errors per provider was 0.5 (0–1) and two (0.25–3) for the novel user interface and standard electronic medical record interface, respectively (p = .007). Conclusions:A novel user interface was designed based on the information needs of intensive care unit providers with a specific goal of development being the reduction of task load and errors of cognition associated with filtering, extracting, and using medical data contained within a comprehensive electronic medical record. The results of this simulated clinical experiment suggest that the configuration of the intensive care unit user interface contributes significantly to the task load, time to task completion, and number of errors of cognition associated with the identification, and subsequent use, of relevant patient data. Task-specific user interfaces, developed from an understanding of provider information requirements, offer advantages over interfaces currently available within a standard electronic medical record.

Off-hour presentation and outcomes in patients with acute myocardial infarction: systematic review and meta-analysis

Objective To assess the association between off-hour (weekends and nights) presentation, door to balloon times, and mortality in patients with acute myocardial infarction. Data sources Medline in-process and other non-indexed citations, Medline, Embase, Cochrane Database of Systematic Reviews, and Scopus through April 2013. Study selection Any study that evaluated the association between time of presentation to a healthcare facility and mortality or door to balloon times among patients with acute myocardial infarction was included. Data extraction Studies’ characteristics and outcomes data were extracted. Quality of studies was assessed with the Newcastle-Ottawa scale. A random effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I2. Results 48 studies with fair quality, enrolling 1 896 859 patients, were included in the meta-analysis. 36 studies reported mortality outcomes for 1 892 424 patients with acute myocardial infarction, and 30 studies reported door to balloon times for 70 534 patients with ST elevation myocardial infarction (STEMI). Off-hour presentation for patients with acute myocardial infarction was associated with higher short term mortality (odds ratio 1.06, 95% confidence interval 1.04 to 1.09). Patients with STEMI presenting during off-hours were less likely to receive percutaneous coronary intervention within 90 minutes (odds ratio 0.40, 0.35 to 0.45) and had longer door to balloon time by 14.8 (95% confidence interval 10.7 to 19.0) minutes. A diagnosis of STEMI and countries outside North America were associated with larger increase in mortality during off-hours. Differences in mortality between off-hours and regular hours have increased in recent years. Analyses were associated with statistical heterogeneity. Conclusion This systematic review suggests that patients with acute myocardial infarction presenting during off-hours have higher mortality, and patients with STEMI have longer door to balloon times. Clinical performance measures may need to account for differences arising from time of presentation to a healthcare facility.

Derivation and Validation of Automated Electronic Search Strategies to Extract Charlson Comorbidities From Electronic Medical Records

OBJECTIVE To develop and validate automated electronic note search strategies (automated digital algorithm) to identify Charlson comorbidities. PATIENTS AND METHODS The automated digital algorithm was built by a series of programmatic queries applied to an institutional electronic medical record database. The automated digital algorithm was derived from secondary analysis of an observational cohort study of 1447 patients admitted to the intensive care unit from January 1 through December 31, 2006, and validated in an independent cohort of 240 patients. The sensitivity, specificity, and positive and negative predictive values of the automated digital algorithm and International Classification of Diseases, Ninth Revision (ICD-9) codes were compared with comprehensive medical record review (reference standard) for the Charlson comorbidities. RESULTS In the derivation cohort, the automated digital algorithm achieved a median sensitivity of 100% (range, 99%-100%) and a median specificity of 99.7% (range, 99%-100%). In the validation cohort, the sensitivity of the automated digital algorithm ranged from 91% to 100%, and the specificity ranged from 98% to 100%. The sensitivity of the ICD-9 codes ranged from 8% for dementia to 100% for leukemia, whereas specificity ranged from 86% for congestive heart failure to 100% for leukemia, dementia, and AIDS. CONCLUSION Our results suggest that search strategies that use automated electronic search strategies to extract Charlson comorbidities from the clinical notes contained within the electronic medical record are feasible and reliable. Automated digital algorithm outperformed ICD-9 codes in all the Charlson variables except leukemia, with greater sensitivity, specificity, and positive and negative predictive values.

Limiting ventilator-induced lung injury through individual electronic medical record surveillance

Background:To improve the safety of ventilator care and decrease the risk of ventilator-induced lung injury, we designed and tested an electronic algorithm that incorporates patient characteristics and ventilator settings, allowing near-real-time notification of bedside providers about potentially injurious ventilator settings. Methods:Electronic medical records of consecutive patients who received invasive ventilation were screened in three Mayo Clinic Rochester intensive care units. The computer system alerted bedside providers via the text paging notification about potentially injurious ventilator settings. Alert criteria included a Pao2/Fio2 ratio of <300 mm Hg, free text search for the words “edema” or “bilateral + infiltrates” on the chest radiograph report, a tidal volume of >8 mL/kg predicted body weight (based on patient gender and height), a plateau pressure of >30 cm H2O, and a peak airway pressure of >35 cm H2O. Respiratory therapists answered a brief online satisfaction survey. Ventilator-induced lung injury risk was compared before and after the introduction of ventilator-induced lung injury alert. Findings:The prevalence of acute lung injury was 42% (n = 490) among 1,159 patients receiving >24 hrs of invasive ventilation. The system sent 111 alerts for 80 patients, with a positive predictive value of 59%. The exposure to potentially injurious ventilation decreased after the intervention from 40.6 ± 74.6 hrs to 26.9 ± 77.3 hrs (p = .004). Interpretations:Electronic medical record surveillance of mechanically ventilated patients accurately detects potentially injurious ventilator settings and is able to influence bedside practice at moderate costs. Its implementation is associated with decreased patient exposure to potentially injurious mechanical ventilation settings.

Novel Representation of Clinical Information in the ICU: Developing User Interfaces which Reduce Information Overload.

The introduction of electronic medical records (EMR) and computerized physician order entry (CPOE) into the intensive care unit (ICU) is transforming the way health care providers currently work. The challenge facing developers of EMRs is to create products which add value to systems of health care delivery. As EMRs become more prevalent, the potential impact they have on the quality and safety, both negative and positive, will be amplified. In this paper we outline the key barriers to effective use of EMR and describe the methodology, using a worked example of the output. AWARE (Ambient Warning and Response Evaluation), is a physician led, electronic-environment enhancement program in an academic, tertiary care institutions ICU. The development process is focused on reducing information overload, improving efficiency and eliminating medical error in the ICU.

Data Utilization for Medical Decision Making at the Time of Patient Admission to Icu

Objectives:Information overload in electronic medical records can impede providers’ ability to identify important clinical data and may contribute to medical error. An understanding of the information requirements of ICU providers will facilitate the development of information systems that prioritize the presentation of high-value data and reduce information overload. Our objective was to determine the clinical information needs of ICU physicians, compared to the data available within an electronic medical record. Design:Prospective observational study and retrospective chart review. Setting:Three ICUs (surgical, medical, and mixed) at an academic referral center. Subjects:Newly admitted ICU patients and physicians (residents, fellows, and attending staff). Measurements and Main Results:The clinical information used by physicians during the initial diagnosis and treatment of admitted patients was captured using a questionnaire. Clinical information concepts were ranked according to the frequency of reported use (primary outcome) and were compared to information availability in the electronic medical record (secondary outcome). Nine hundred twenty-five of 1,277 study questionnaires (408 patients) were completed. Fifty-one clinical information concepts were identified as being useful during ICU admission. A median (interquartile range) of 11 concepts (6–16) was used by physicians per patient admission encounter with four used greater than 50% of the time. Over 25% of the clinical data available in the electronic medical record was never used, and only 33% was used greater than 50% of the time by admitting physicians. Conclusions:Physicians use a limited number of clinical information concepts at the time of patient admission to the ICU. The electronic medical record contains an abundance of unused data. Better electronic data management strategies are needed, including the priority display of frequently used clinical concepts within the electronic medical record, to improve the efficiency of ICU care.

The implementation of clinician designed, human-centered electronic medical record viewer in the intensive care unit: A pilot step-wedge cluster randomized trial

OBJECTIVES AWARE (Ambient Warning and Response Evaluation) is a novel electronic medical record (EMR) dashboard designed by clinicians to support bedside clinical information management in the ICU. AWARE sits on top of pre-existing, comprehensive EMR systems. The purpose of the study was to test the acceptance and impact of AWARE on data management in live clinical ICU settings. The primary outcome measure was observed efficiency of data utilization as determined by time spent in data gathering before morning rounds. DESIGN Step wedge cluster randomization trial. SETTING Four ICUs (surgical, medical, and mixed) at an academic referral center. SUBJECTS All members of the critical care team participating in morning ICU rounds. INTERVENTION Pilot implementation of a novel EMR interface with direct observation and survey. MEASUREMENTS AND MAIN RESULTS The study took place between April and July 2012. A total of 80 and 63 direct observations were made in the pre- and post-implementation study periods respectively. The time spent on pre-round data gathering per patient decreased from 12 (10-15) to 9 (7.3-11) min for pre- and post-implementation phases respectively (p=0.03). Compared to the existing EMR, information management (data presentation format, efficiency of data access) was reported to be better after AWARE implementation. AWARE made the task of gathering data for rounds significantly less difficult and mentally demanding. CONCLUSIONS The introduction of a novel, patient-centered EMR viewer for the ICU was associated with improved efficiency and ease of clinical data management compared to the standard EMR.

The role of potentially preventable hospital exposures in the development of acute respiratory distress syndrome: a population-based study.

Objective:Acute respiratory distress syndrome is a common complication of critical illness, with high mortality and limited treatment options. Preliminary studies suggest that potentially preventable hospital exposures contribute to acute respiratory distress syndrome development. We aimed to determine the association between specific hospital exposures and the rate of acute respiratory distress syndrome development among at-risk patients. Design:Population-based, nested, Matched case-control study. Patients:Consecutive adults who developed acute respiratory distress syndrome from January 2001 through December 2010 during their hospital stay (cases) were matched to similar-risk patients without acute respiratory distress syndrome (controls). They were matched for 6 baseline characteristics. Interventions:None. Measurements and Main Results:Trained investigators blinded to outcome of interest reviewed medical records for evidence of specific exposures, including medical and surgical adverse events, inadequate empirical antimicrobial treatment, hospital-acquired aspiration, injurious mechanical ventilation, transfusion, and fluid and medication administration. Conditional logistic regression was used to calculate the risk associated with individual exposures. During the 10-year period, 414 patients with hospital-acquired acute respiratory distress syndrome were identified and matched to 414 at-risk, acute respiratory distress syndrome-free controls. Adverse events were highly associated with acute respiratory distress syndrome development (odds ratio, 6.2; 95% CI, 4.0–9.7), as were inadequate antimicrobial therapy, mechanical ventilation with injurious tidal volumes, hospital-acquired aspiration, and volume of blood products transfused and fluids administered. Exposure to antiplatelet agents during the at-risk period was associated with a decreased risk of acute respiratory distress syndrome. Rate of adverse hospital exposures and prevalence of acute respiratory distress syndrome decreased during the study period. Conclusions:Prevention of adverse hospital exposures in at-risk patients may limit the development of acute respiratory distress syndrome.

Actual versus ideal body weight for acute kidney injury diagnosis and classification in critically Ill patients

BackgroundIn the current acute kidney injury (AKI) definition, the urine output (UO) criterion does not specify which body weights (BW), i.e. actual (ABW) versus ideal (IBW), should be used to diagnose and stage AKI, leading to heterogeneity across research studies.MethodsThis is a single center, retrospective, observational study conducted at a tertiary referral hospital. All adult patients who were admitted to intensive care units (ICUs) at our institution for a minimum of 6 continuous hours between January and March 2010 and had a urinary catheter for hourly urine output monitoring were eligible for this study. Patients’ AKI stages, based on UO criterion, were assessed by calculating each milliliter of urine per kilogram per hour, using ABW versus IBW.ResultsA total of 493 ICU patients were included in the analysis. The median ABW and IBW were 82 (IQR 68-96) and 70 (IQR 60-77) kg, respectively. Using the IBW criterion, 154 patients (31.2%) were diagnosed with AKI, while 204 (41.4%) were diagnosed using the ABW measurement (P-value < .01). Patients who had AKI regardless of BW type had an adjusted odds ratio of 1.76 (95% CI 1.05-2.95) for 90-day mortality, whereas patients who had AKI according to ABW but not IBW had no significant increase in the risk of 90-day mortality, adjusted OR 0.76; (95% CI 0.25-1.91), compared to patients who had no AKI.ConclusionsUsing ABW to diagnose and stage AKI by UO criterion is more sensitive and less specific than IBW. Based on the application of the definition, different BW types could be utilized.

Development and validation of electronic surveillance tool for acute kidney injury: A retrospective analysis.

INTRODUCTION Timely detection of acute kidney injury (AKI) facilitates prevention of its progress and potentially therapeutic interventions. The study objective is to develop and validate an electronic surveillance tool (AKI sniffer) to detect AKI in 2 independent retrospective cohorts of intensive care unit (ICU) patients. The primary aim is to compare the sensitivity, specificity, and positive and negative predictive values of AKI sniffer performance against a reference standard. METHODS This study is conducted in the ICUs of a tertiary care center. The derivation cohort study subjects were Olmsted County, MN, residents admitted to all Mayo Clinic ICUs from July 1, 2010, through December 31, 2010, and the validation cohort study subjects were all patients admitted to a Mayo Clinic, Rochester, campus medical/surgical ICU on January 12, 2010, through March 23, 2010. All included records were reviewed by 2 independent investigators who adjudicated AKI using the Acute Kidney Injury Network criteria; disagreements were resolved by a third reviewer. This constituted the reference standard. An electronic algorithm was developed; its precision and reliability were assessed in comparison with the reference standard in 2 separate cohorts, derivation and validation. RESULTS Of 1466 screened patients, a total of 944 patients were included in the study: 482 for derivation and 462 for validation. Compared with the reference standard in the validation cohort, the sensitivity and specificity of the AKI sniffer were 88% and 96%, respectively. The Cohen κ (95% confidence interval) agreement between the electronic and the reference standard was 0.84 (0.78-0.89) and 0.85 (0.80-0.90) in the derivation and validation cohorts. CONCLUSION Acute kidney injury can reliably and accurately be detected electronically in ICU patients. The presented method is applicable for both clinical (decision support) and research (enrollment for clinical trials) settings. Prospective validation is required.