E. Andrew Balas

Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success

Abstract Objective To identify features of clinical decision support systems critical for improving clinical practice. Design Systematic review of randomised controlled trials. Data sources Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews. Study selection Studies had to evaluate the ability of decision support systems to improve clinical practice. Data extraction Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature. Results Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P < 0.00001), provision of recommendations rather than just assessments (P = 0.0187), provision of decision support at the time and location of decision making (P = 0.0263), and computer based decision support (P = 0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations. Conclusions Several features were closely correlated with decision support systems ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.

Healthcare via Cell Phones: A Systematic Review

Regular care and informational support are helpful in improving disease-related health outcomes. Communication technologies can help in providing such care and support. The purpose of this study was to evaluate the empirical evidence related to the role of cell phones and text messaging interventions in improving health outcomes and processes of care. Scientific literature was searched to identify controlled studies evaluating cell phone voice and text message interventions to provide care and disease management support. Searches identified 25 studies that evaluated cell phone voice and text messaging interventions, with 20 randomized controlled trials and 5 controlled studies. Nineteen studies assessed outcomes of care and six assessed processes of care. Selected studies included 38,060 participants with 10,374 adults and 27,686 children. They covered 12 clinical areas and took place in 13 countries. Frequency of message delivery ranged from 5 times per day for diabetes and smoking cessation support to once a week for advice on how to overcome barriers and maintain regular physical activity. Significant improvements were noted in compliance with medicine taking, asthma symptoms, HbA1C, stress levels, smoking quit rates, and self-efficacy. Process improvements were reported in lower failed appointments, quicker diagnosis and treatment, and improved teaching and training. Cost per text message was provided by two studies. The findings that enhancing standard care with reminders, disease monitoring and management, and education through cell phone voice and short message service can help improve health outcomes and care processes have implications for both patients and providers.

Computerization of Primary Care in the United States

The objective of this study was to assess the current level of information technology use by primary care physicians in the U.S. Primary care physicians listed by the American Medical Association were contacted by e-mail and asked to complete a Web-based questionnaire. A total of 2,145 physicians responded. Overall, between 20% and 25% of primary care physicians reported using electronic medical records, e-prescribing, point-of-care decision support tools, and electronic communication with patients. This indicates a slow rate of adoption since 2000. Differences in adoption rates suggest that future surveys need to differentiate primary care and office-based physicians by specialty. An important finding is that one-third of the physicians surveyed expressed no interest in the four IT applications. Overcoming this barrier may require efforts by medical specialty societies to educate their members in the benefits of IT in practice. The majority of physicians perceived benefits of IT, but they cited costs, vendor inability to deliver acceptable products, and concerns about privacy and confidentiality as major barriers to implementation of IT applications. Overcoming the cost barrier may require that payers and the federal government share the costs of implementing these IT applications.

Effective and Sustainable Multimedia Education for Children With Asthma: A Randomized Controlled Trial

Traditional asthma education has been found to be time-consuming and limited in terms of availability. Our goal was to improve asthma care by meeting special needs of children with asthma and by building on their skills in using new technologies. Multimedia asthma education occurred through the viewing of short, animated vignettes on an exam room computer. Evaluation of 228 children showed significant improvement in days of asthma symptoms (p ??.01), in emergency room visits (p ??.05), in school days missed (p ??.05), and in days of activity limitation from baseline to the year-end follow-up (p ??.05). Effective multimedia education, if integrated into pediatric practice to supplement existing asthma care, can improve clinical outcomes.

Big Data Clinical Research: Validity, Ethics, and Regulation.

Electronic Health Records (EHR) promise improvement for patient care and also offer great value for biomedical research including clinical, public health, and health services research. Unfortunately, the full potential of EHR big data research has remained largely unrealized. The purpose of this study was to identify rate limiting factors, and develop recommendations to better balance unrestricted extramural EHR access with legitimate safeguarding of EHR data in retrospective research. By exploring primary, secondary, and tertiary sources, this review identifies external constraints and provides a comparative analysis of social influencers in retrospective EHR-based research. Results indicate that EHRs have the advantage of reflecting the reality of patient care but also show a frequency of between 4.3-86% of incomplete and inaccurate data in various fields. The rapid spread of alternative analytics for health data challenges traditional interpretations of confidentiality protections. A confusing multiplicity of controls creates barriers to big data EHR research. More research on the use of EHR big data is likely to improve accuracy and validity. Information governance and research approval processes should be simplified. Comprehensive regulatory policies that do not exclusively cover health care entities, are needed. Finally, new computing safeguards are needed to address public concerns, like research access only to aggregate data and not to individually identifiable information.

Technology Transfer From Biomedical Research to Clinical Practice Measuring Innovation Performance

Studies documented 17 years of transfer time from clinical trials to practice of care. Launched in 2002, the National Institutes of Health (NIH) translational research initiative needs to develop metrics for impact assessment. A recent White House report highlighted that research and development productivity is declining as a result of increased research spending while the new drugs output is flat. The goal of this study was to develop an expanded model of research-based innovation and performance thresholds of transfer from research to practice. Models for transfer of research to practice have been collected and reviewed. Subsequently, innovation pathways have been specified based on common characteristics. An integrated, intellectual property transfer model is described. The central but often disregarded role of research innovation disclosure is highlighted. Measures of research transfer and milestones of progress have been identified based on the Association of University Technology Managers 2012 performance reports. Numeric milestones of technology transfer are recommended at threshold (top 50%), target (top 25%), and stretch goal (top 10%) performance levels. Transfer measures and corresponding target levels include research spending to disclosure (<

Interoperable Electronic Patient Records for Health Care Improvement

1.88 million), disclosure to patents (>0.81), patents to start-up (>0.1), patents to licenses (>2.25), and average per license income (>

Clinical Trials of Information Interventions

48,000). Several limitations of measurement are described. Academic institutions should take strategic steps to bring innovation to the center of scholarly discussions. Research on research, particularly on pathways to disclosures, is needed to improve R&D productivity. Researchers should be informed about the technology transfer performance of their institution and regulations should better support innovators.

Are university rankings useful to improve research? A systematic review

Pressing needs of cost-effectiveness in healthcare and opportunities of emerging electronic health record technologies offer unprecedented chance for progress. Ongoing health care improvement and patient safety initiatives demand new information collection and communication technologies (e.g., Centers for Medicaid and Medicare Services, Joint Commission, National Patient Safety Foundation, public health surveillance). Particularly, desire for faster action and cost-effective health care drive unprecedented investments in electronic patient records worldwide. Recognizing these opportunities, many countries and the World Health Organization have launched several major health care improvement initiatives that are driven by new electronic record technologies. In the United States, historic

Electronic Communication With Patients: Evaluation of Distance Medicine Technology

19 billion investment is provided through the American Recovery and Reinvestment Act of 2009. Models of sharing electronic patient data and citizen expectations for personal electronic health records will be reviewed. Regional health information networks and other information sharing initiatives depend on the interoperability of systems. Ultimately, the recent flood of health information standards needs to be balanced with actual interoperability opportunities. It is anticipated that the current policy discussions on the meaningful use of electronic health records will have major beneficial technical and also reimbursement implications.