James D. Carpenter

The state of the art in clinical knowledge management: An inventory of tools and techniques

PURPOSE To explore the need for, and use of, high-quality, collaborative, clinical knowledge management (CKM) tools and techniques to manage clinical decision support (CDS) content. METHODS In order to better understand the current state of the art in CKM, we developed a survey of potential CKM tools and techniques. We conducted an exploratory study by querying a convenience sample of respondents about their use of specific practices in CKM. RESULTS The following tools and techniques should be priorities in organizations interested in developing successful computer-based provider order entry (CPOE) and CDS implementations: (1) a multidisciplinary team responsible for creating and maintaining the clinical content; (2) an external organizational repository of clinical content with web-based viewer that allows anyone in the organization to review it; (3) an online, collaborative, interactive, Internet-based tool to facilitate content development; (4) an enterprise-wide tool to maintain the controlled clinical terminology concepts. Even organizations that have been successfully using computer-based provider order entry with advanced clinical decision support features for well over 15 years are not using all of the CKM tools or practices that we identified. CONCLUSIONS If we are to further stimulate progress in the area of clinical decision support, we must continue to develop and refine our understanding and use of advanced CKM capabilities.

Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study

BackgroundThe purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed systems in the U.S.MethodsGuided by the Multiple Perspectives Framework, the authors conducted ethnographic field studies at two community hospitals and five ambulatory clinic organizations across the U.S. Using a Rapid Assessment Process, a multidisciplinary research team: gathered preliminary assessment data; conducted on-site interviews, observations, and field surveys; analyzed data using both template and grounded methods; and developed universal themes. A panel of experts produced recommended practices.ResultsThe team identified ten themes related to CDS and KM. These include: 1) workflow; 2) knowledge management; 3) data as a foundation for CDS; 4) user computer interaction; 5) measurement and metrics; 6) governance; 7) translation for collaboration; 8) the meaning of CDS; 9) roles of special, essential people; and 10) communication, training, and support. Experts developed recommendations about each theme. The original Multiple Perspectives framework was modified to make explicit a new theoretical construct, that of Translational Interaction.ConclusionsThese ten themes represent areas that need attention if a clinic or community hospital plans to implement and successfully utilize CDS. In addition, they have implications for workforce education, research, and national-level policy development. The Translational Interaction construct could guide future applied informatics research endeavors.

Use of order sets in inpatient computerized provider order entry systems: A comparative analysis of usage patterns at seven sites

BACKGROUND Many computerized provider order entry (CPOE) systems include the ability to create electronic order sets: collections of clinically related orders grouped by purpose. Order sets promise to make CPOE systems more efficient, improve care quality and increase adherence to evidence-based guidelines. However, the development and implementation of order sets can be expensive and time-consuming and limited literature exists about their utilization. METHODS Based on analysis of order set usage logs from a diverse purposive sample of seven sites with commercially and internally developed inpatient CPOE systems, we developed an original order set classification system. Order sets were categorized across seven non-mutually exclusive axes: admission/discharge/transfer (ADT), perioperative, condition-specific, task-specific, service-specific, convenience, and personal. In addition, 731 unique subtypes were identified within five axes: four in ADT (S=4), three in perioperative, 144 in condition-specific, 513 in task-specific, and 67 in service-specific. RESULTS Order sets (n=1914) were used a total of 676,142 times at the participating sites during a one-year period. ADT and perioperative order sets accounted for 27.6% and 24.2% of usage respectively. Peripartum/labor, chest pain/acute coronary syndrome/myocardial infarction and diabetes order sets accounted for 51.6% of condition-specific usage. Insulin, angiography/angioplasty and arthroplasty order sets accounted for 19.4% of task-specific usage. Emergency/trauma, obstetrics/gynecology/labor delivery and anesthesia accounted for 32.4% of service-specific usage. Overall, the top 20% of order sets accounted for 90.1% of all usage. Additional salient patterns are identified and described. CONCLUSION We observed recurrent patterns in order set usage across multiple sites as well as meaningful variations between sites. Vendors and institutional developers should identify high-value order set types through concrete data analysis in order to optimize the resources devoted to development and implementation.