Insook Cho

Overrides of medication-related clinical decision support alerts in outpatients

BACKGROUND Electronic prescribing is increasingly used, in part because of government incentives for its use. Many of its benefits come from clinical decision support (CDS), but often too many alerts are displayed, resulting in alert fatigue. OBJECTIVE To characterize the override rates for medication-related CDS alerts in the outpatient setting, the reasons cited for overrides at the time of prescribing, and the appropriateness of overrides. METHODS We measured CDS alert override rates and the coded reasons for overrides cited by providers at the time of prescribing. Our primary outcome was the rate of CDS alert overrides; our secondary outcomes were the rate of overrides by alert type, reasons cited for overrides at the time of prescribing, and override appropriateness for a subset of 600 alert overrides. Through detailed chart reviews of alert override cases, and selective literature review, we developed appropriateness criteria for each alert type, which were modified iteratively as necessary until consensus was reached on all criteria. RESULTS We reviewed 157,483 CDS alerts (7.9% alert rate) on 2,004,069 medication orders during the study period. 82,889 (52.6%) of alerts were overridden. The most common alerts were duplicate drug (33.1%), patient allergy (16.8%), and drug-drug interactions (15.8%). The most likely alerts to be overridden were formulary substitutions (85.0%), age-based recommendations (79.0%), renal recommendations (78.0%), and patient allergies (77.4%). An average of 53% of overrides were classified as appropriate, and rates of appropriateness varied by alert type (p<0.0001) from 12% for renal recommendations to 92% for patient allergies. DISCUSSION About half of CDS alerts were overridden by providers and about half of the overrides were classified as appropriate, but the likelihood of overriding an alert varied widely by alert type. Refinement of these alerts has the potential to improve the relevance of alerts and reduce alert fatigue.

Are We Heeding the Warning Signs? Examining Providers’ Overrides of Computerized Drug-Drug Interaction Alerts in Primary Care

Background Health IT can play a major role in improving patient safety. Computerized physician order entry with decision support can alert providers to potential prescribing errors. However, too many alerts can result in providers ignoring and overriding clinically important ones. Objective To evaluate the appropriateness of providers’ drug-drug interaction (DDI) alert overrides, the reasons why they chose to override these alerts, and what actions they took as a consequence of the alert. Design A cross-sectional, observational study of DDI alerts generated over a three-year period between January 1st, 2009, and December 31st, 2011. Setting Primary care practices affiliated with two Harvard teaching hospitals. The DDI alerts were screened to minimize the number of clinically unimportant warnings. Participants A total of 24,849 DDI alerts were generated in the study period, with 40% accepted. The top 62 providers with the highest override rate were identified and eight overrides randomly selected for each (a total of 496 alert overrides for 438 patients, 3.3% of the sample). Results Overall, 68.2% (338/496) of the DDI alert overrides were considered appropriate. Among inappropriate overrides, the therapeutic combinations put patients at increased risk of several specific conditions including: serotonin syndrome (21.5%, n=34), cardiotoxicity (16.5%, n=26), or sharp falls in blood pressure or significant hypotension (28.5%, n=45). A small number of drugs and DDIs accounted for a disproportionate share of alert overrides. Of the 121 appropriate alert overrides where the provider indicated they would “monitor as recommended”, a detailed chart review revealed that only 35.5% (n=43) actually did. Providers sometimes reported that patients had already taken interacting medications together (15.7%, n=78), despite no evidence to confirm this. Conclusions and Relevance We found that providers continue to override important and useful alerts that are likely to cause serious patient injuries, even when relatively few false positive alerts are displayed.

Patient-centered interventions to improve medication management and adherence: A qualitative review of research findings

OBJECTIVE Patient-centered approaches to improving medication adherence hold promise, but evidence of their effectiveness is unclear. This review reports the current state of scientific research around interventions to improve medication management through four patient-centered domains: shared decision-making, methods to enhance effective prescribing, systems for eliciting and acting on patient feedback about medication use and treatment goals, and medication-taking behavior. METHODS We reviewed literature on interventions that fell into these domains and were published between January 2007 and May 2013. Two reviewers abstracted information and categorized studies by intervention type. RESULTS We identified 60 studies, of which 40% focused on patient education. Other intervention types included augmented pharmacy services, decision aids, shared decision-making, and clinical review of patient adherence. Medication adherence was an outcome in most (70%) of the studies, although 50% also examined patient-centered outcomes. CONCLUSIONS We identified a large number of medication management interventions that incorporated patient-centered care and improved patient outcomes. We were unable to determine whether these interventions are more effective than traditional medication adherence interventions. PRACTICE IMPLICATIONS Additional research is needed to identify effective and feasible approaches to incorporate patient-centeredness into the medication management processes of the current health care system, if appropriate.

Design and implementation of a standards-based interoperable clinical decision support architecture in the context of the Korean EHR

BACKGROUND In 2000 the Korean government initiated efforts to secure healthcare accessibility and efficiency anytime and anywhere via the nationwide healthcare information system by the end of 2010. According to the master plan, electronic health record (EHR) research and development projects were designed in 2005. One subproject was the design and implementation of standards-based interoperable clinical decision support (CDS) capabilities in the context of the EHR system. OBJECTIVE The purpose of this study was to describe the challenges, process, and outcomes of defining and implementing a national CDS architecture to stimulate and motivate the widespread adoption of CDS services in Korea. METHODS CDS requirements and design principles were established by conducting a selective literature review and a survey of clinicians, managers, and hospital and industrial health information technology engineers regarding issues related to CDS architectures. The previous relevant works of the American Medical Informatics Association, the Healthcare Information and Management Systems Society, and Health Level Seven were used to validate the scope and themes of the service architecture. The Arden Syntax, Standards-Based Sharable Active Guideline Environment, First DataBank, and SEBASTIAN approaches were used to assess the coverage of the application architecture thus defined. A CDS prototype of an outpatient hypertension management system was implemented and assessed in a simulated experimental setting to evaluate the feasibility of the proposed architecture. RESULTS Four CDS service features were identified: knowledge application, knowledge management, audit and evaluation, and CDS and knowledge governance. Five core components of CDS application architecture were also identified: knowledge-execution component, knowledge-authoring component, data-interface component, knowledge repository, and service-interface component. The coverage and characteristics of the architecture identified herein were found to be comparable with those described previously. Two scenarios of deployment architecture were identified in the context of Korean healthcare. The preliminary feasibility test revealed that the architecture exhibited good performance and made it easy to integrate patient data. CONCLUSION We have described the efforts that have been made to realize CDS service features, core components, application, and deployment architectures in the context of the Korean EHR. These outcomes showed the potential to contribute to the adoption of CDS at the national level.

Braden Scale: evaluation of clinical usefulness in an intensive care unit

AIM This paper is a report of a study conducted to determine the usability and utility of the Braden in intensive care units. BACKGROUND An understanding of the clinical usage of the Braden Scale is valuable when considering the incidence of pressure ulcers in a critical-care setting. METHODS A retrospective analysis of 21,115 hospital-days of 715 inpatients in an intensive-care unit in 2006 in South Korea was applied to data extracted electronically from an electronic medical record system in October 2007. RESULTS Of the 715 patients, 42 (5.9%) developed a pressure ulcer, corresponding to an incidence density of 198 ulcers per 1000 hospital-days. The usage rate of the Braden Scale was 11.26%, and an analysis of its utility, based on a receiver operating characteristic analysis with the cutoff set at 13, gave sensitivity, specificity, positive predictive values and negative predictive values of 75.9%, 47.3%, 18.1% and 92.8% respectively. There were weak correlations between the scores and nursing interventions except for the category of position changes. The variety of nursing interventions was also limited. CONCLUSION Our data suggest that the Braden Scale has a very low usage rate and a low-to-moderate positive predictive performance. Our quantification of the relationship between Braden Scale score and nursing interventions indicates the need for a more comprehensive and fundamental approach to the use of this scale.

Evaluation of the Expressiveness of an ICNP-based Nursing Data Dictionary in a Computerized Nursing Record System

This study evaluated the domain completeness and expressiveness issues of the International Classification for Nursing Practice-based (ICNP) nursing data dictionary (NDD) through its application in an enterprise electronic medical record (EMR) system as a standard vocabulary at a single tertiary hospital in Korea. Data from 2,262 inpatients obtained over a period of 9 weeks (May to July 2003) were extracted from the EMR system for analysis. Among the 530,218 data-input events, 401,190 (75.7%) were entered from the NDD, 20,550 (3.9%) used only free text, and 108,478 (20.4%) used a combination of coded data and free text. A content analysis of the free-text events showed that 80.3% of the expressions could be found in the NDD, whereas 10.9% were context-specific expressions such as direct quotations of patient complaints and responses, and references to the care plan or orders of physicians. A total of 7.8% of the expressions was used for a supplementary purpose such as adding a conjunction or end verb to make an expression appear as natural language. Only 1.0% of the expressions were identified as not being covered by the NDD. This evaluation study demonstrates that the ICNP-based NDD has sufficient power to cover most of the expressions used in a clinical nursing setting.

Using EHR data to predict hospital-acquired pressure ulcers: A prospective study of a Bayesian Network model

BACKGROUND Hospital-acquired pressure ulcers (HAPU) are common among inpatients and create substantial morbidity, mortality, and costs, but prevention strategies have been only variably effective. OBJECTIVES To develop and assess the impact of a decision support intervention to predict HAPU on the prevalence of ulcers and length of stay in an intensive care unit (ICU), and on the user adoption rate and attitudes. METHODS We compared the HAPU prevalence before and after introducing the intervention, and surveyed the users. We used a Bayesian Network model that was validated in previous studies and linked to the electronic health record system in an application called Pressure Ulcer (PU) Manager. The intervention group included 866 at-risk patients in the surgical ICUs of a tertiary teaching hospital over a 6-month period in 2009 and 2010; the controls were 348 patients from a 6-month baseline period in 2006 and 2007. RESULTS In the intervention group, the overall HAPU prevalence rate fell from 21% to 4.0% and the ICU length of stay shortened from 7.6 to 5.2 days. After adjustment for primary diagnoses and illness severity, the intervention group was significantly less likely than the baseline group to develop HAPU [odds ratio (OR)=0.1, p<0.0001] and had a shorter ICU length of stay (OR=0.67, p<0.0001). Data entry regarding ulcer severity and body site increased, and the participants used PU Manager more than once a day for over 80% of eligible cases. Attitudes toward PU Manager were positive. CONCLUSIONS This decision support approach reduced the prevalence of HAPU tenfold and the ICU length of stay by about one-third. Furthermore, the nurses had favorable attitudes toward using it.

Using electronic health records to address overweight and obesity: a systematic review.

CONTEXT Overweight and obesity are problems of tremendous public health importance, but clinicians often fail to discuss weight management with their patients. Electronic health records (EHRs) have improved quality of care for some conditions and could be an effective mechanism for helping clinicians address overweight and obesity. This review sought to summarize current evidence on the use of EHRs for assessment and management of overweight and obesity. EVIDENCE ACQUISITION The authors searched PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, CINAHL, INSPEC, IEEE Explore, and the ACM Digital Library from their inception through August 15, 2012; analyses were conducted between September 2012 and March 2013. Eligible studies had to involve a new feature or a change in an existing feature within an EHR related to the identification, evaluation, or management of overweight and obesity. Included in the review were RCTs and nonrandomized controlled trials, pre-post studies with a historical control group, and descriptive studies. One reviewer screened all of the titles and abstracts. Citations that were potentially eligible were independently reviewed by two reviewers. Disagreements were resolved by consensus. EVIDENCE SYNTHESIS Of the 1188 unique citations identified, 11 met the inclusion criteria. Seven of these studies were conducted in children and adolescents, and four were conducted in adults. Most of the studies were pre-post studies with a historical control group, and only three were RCTs. Most of the interventions included calculation, display, or plotting of BMI or BMI percentiles; fewer included other features. The majority of studies examined clinician performance outcomes; only two studies examined patient outcomes. CONCLUSIONS Few studies have examined whether EHR-based tools can help clinicians address overweight and obesity, and further studies are needed to examine the effects of EHR features on weight-related outcomes in patients.

Affecting Factors of Nursing Professionalism Perceived by Senior Nursing Students

Purpose: The purpose of this descriptive study was to investigate the level of nursing professionalism and influencing factors of professionalism in nursing students. Method: A convenience sample of 207 subjects were recruited from two universities in I city and one university in S city. The subject for this survey were senior students who finished all clinical practicum to be done before graduation. Results: The mean scores of the nursing professionalism and the satisfaction with clinical practice were 3.43 and 3.28 individually. The mean of self-efficacy and image of nurses were 3.60 and 3.71 individually. Mean of major satisfaction score was 3.88. There were significant correlations among nursing professionalism, satisfaction with clinical practice, self-efficacy, image of nurses and major satisfaction. The most strong factor affecting nursing professionalism was the image of nurses and accounted 52.0 percentage of the variance. Sixty point one percentage of the variance was explained by image of nurses, major satisfaction, religion and satisfaction with clinical practice. Conclusion: To make students have more positive nursing professionalism, strategies enhancing the positive nurse image, clinical satisfaction, and major satisfaction need to be developed during school years.

Modeling a terminology-based electronic nursing record system: an object-oriented approach.

OBJECTIVE The aim of this study was to present our perspectives on healthcare information analysis at a conceptual level and the lessons learned from our experience with the development of a terminology-based enterprise electronic nursing record system - which was one of components in an EMR system at a tertiary teaching hospital in Korea - using an object-oriented system analysis and design concept. METHODS To ensure a systematic approach and effective collaboration, the department of nursing constituted a system modeling team comprising a project manager, systems analysts, user representatives, an object-oriented methodology expert, and healthcare informaticists (including the authors). A rational unified process (RUP) and the Unified Modeling Language were used as a development process and for modeling notation, respectively. RESULTS From the scenario and RUP approach, user requirements were formulated into use case sets and the sequence of activities in the scenario was depicted in an activity diagram. The structure of the system was presented in a class diagram. CONCLUSION This approach allowed us to identify clearly the structural and behavioral states and important factors of a terminology-based ENR system (e.g., business concerns and system design concerns) according to the viewpoints of both domain and technical experts.