Donald Levick

Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention

BackgroundWe describe and evaluate the development and use of a Clinical Decision Support (CDS) intervention; an alert, in response to an identified medical error of overuse of a diagnostic laboratory test in a Computerized Physician Order Entry (CPOE) system. CPOE with embedded CDS has been shown to improve quality of care and reduce medical errors. CPOE can also improve resource utilization through more appropriate use of laboratory tests and diagnostic studies. Observational studies are necessary in order to understand how these technologies can be successfully employed by healthcare providers.MethodsThe error was identified by the Test Utilization Committee (TUC) in September, 2008 when they noticed critical care patients were being tested daily, and sometimes twice daily, for B-Type Natriuretic Peptide (BNP). Repeat and/or serial BNP testing is inappropriate for guiding the management of heart failure and may be clinically misleading. The CDS intervention consists of an expert rule that searches the system for a BNP lab value on the patient. If there is a value and the value is within the current hospital stay, an advisory is displayed to the ordering clinician. In order to isolate the impact of this intervention on unnecessary BNP testing we applied multiple regression analysis to the sample of 41,306 patient admissions with at least one BNP test at LVHN between January, 2008 and September, 2011.ResultsOur regression results suggest the CDS intervention reduced BNP orders by 21% relative to the mean. The financial impact of the rule was also significant. Multiplying by the direct supply cost of

Differential Diagnosis Generators: an Evaluation of Currently Available Computer Programs

28.04 per test, the intervention saved approximately

A mixed methods study of clinical information availability in obstetric triage and prenatal offices

92,000 per year.ConclusionsThe use of alerts has great positive potential to improve care, but should be used judiciously and in the appropriate environment. While these savings may not be generalizable to other interventions, the experience at LVHN suggests that appropriately designed and carefully implemented CDS interventions can have a substantial impact on the efficiency of care provision.

The Consequences of Electronic Health Record Adoption for Physician Productivity and Birth Outcomes

BackgroundDifferential diagnosis (DDX) generators are computer programs that generate a DDX based on various clinical data.ObjectiveWe identified evaluation criteria through consensus, applied these criteria to describe the features of DDX generators, and tested performance using cases from the New England Journal of Medicine (NEJM©) and the Medical Knowledge Self Assessment Program (MKSAP©).MethodsWe first identified evaluation criteria by consensus. Then we performed Google® and Pubmed searches to identify DDX generators. To be included, DDX generators had to do the following: generate a list of potential diagnoses rather than text or article references; rank or indicate critical diagnoses that need to be considered or eliminated; accept at least two signs, symptoms or disease characteristics; provide the ability to compare the clinical presentations of diagnoses; and provide diagnoses in general medicine. The evaluation criteria were then applied to the included DDX generators. Lastly, the performance of the DDX generators was tested with findings from 20 test cases. Each case performance was scored one through five, with a score of five indicating presence of the exact diagnosis. Mean scores and confidence intervals were calculated.Key ResultsTwenty three programs were initially identified and four met the inclusion criteria. These four programs were evaluated using the consensus criteria, which included the following: input method; mobile access; filtering and refinement; lab values, medications, and geography as diagnostic factors; evidence based medicine (EBM) content; references; and drug information content source. The mean scores (95% Confidence Interval) from performance testing on a five-point scale were Isabel© 3.45 (2.53, 4.37), DxPlain® 3.45 (2.63–4.27), Diagnosis Pro® 2.65 (1.75–3.55) and PEPID™ 1.70 (0.71–2.69). The number of exact matches paralleled the mean score finding.ConclusionsConsensus criteria for DDX generator evaluation were developed. Application of these criteria as well as performance testing supports the use of DxPlain® and Isabel© over the other currently available DDX generators.

Challenges to Aligning Coordination Technology with Organizations, People, and Processes in Healthcare

Objective: To determine the effect of availability of clinical information from an integrated electronic health record system on pregnancy outcomes at the point of care. Materials and methods: We used provider interviews and surveys to evaluate the availability of pregnancy-related clinical information in ambulatory practices and the hospital, and applied multiple regression to determine whether greater clinical information availability is associated with improvements in pregnancy outcomes and changes in care processes. Our regression models are risk adjusted and include physician fixed effects to control for unobservable characteristics of physicians that are constant across patients and time. Results: Making nonstress test results, blood pressure data, antenatal problem lists, and tubal sterilization requests from office records available to hospital-based providers is significantly associated with reductions in the likelihood of obstetric trauma and other adverse pregnancy outcomes. Better access to prenatal records also increases the probability of labor induction and decreases the probability of Cesarean section (C-section). Availability of lab test results and new diagnoses generated in the hospital at ambulatory offices is associated with fewer preterm births and low-birth-weight babies. Discussion and conclusions: Increased availability of specific clinical information enables providers to deliver better care and improve outcomes, but some types of clinical data are more important than others. More available information does not always result from automated integration of electronic records, but rather from the availability of the source records. Providers depend upon information that they trust to be reliable, complete, consistent, and easily retrievable, even if this requires multiple interfaces.

Integrating commercial ambulatory electronic health records with hospital systems: An evolutionary process

The authors use a mixed-methods approach to investigate how the integration of electronic health records between ambulatory and hospital practices affected physician productivity and birth outcomes at a large health network. Physicians and staff were interviewed during a five-year staged integration of electronic health records, and a direct measure of physician productivity, relative value units, was analyzed concurrently with several measures of birth outcomes. The regression analyses show an 11% reduction in total productivity following the installation of the new system at primary-care sites. The qualitative findings indicate the reduction is attributable to the additional time physicians and staff needed to learn new processes, adopt work practice changes, and develop coordination. Nevertheless, users value the additional integration, especially as information flows back to the ambulatory practices from the hospital. This is supported by increases in treatment intensity over time and a 37% reduction in the severity of adverse birth events.

Extending the Technology Acceptance Model in Healthcare: Identifying the Role of Trust and Shared Information

Healthcare coordination has proven difficult to achieve, even with new coordination technologies such as shared electronic health records. Successful coordination requires alignment of information technology with new organizational structures, reskilled personnel, and reengineering of work processes. We suggest that this is more challenging in the healthcare industry as a result of the need for integrating information across care cycles, payment and regulatory mechanisms, high degree of professional control, failure impact and privacy concerns, and information granularity across the care cycle. We illustrate these challenges with several examples from a qualitative study of the integration of electronic health records between hospital and ambulatory practices.