Stephen J. Jay

Evaluating the Capability of Information Technology to Prevent Adverse Drug Events: A Computer Simulation Approach

BACKGROUND The annual cost of morbidity and mortality due to medication errors in the U.S. has been estimated at

Computers and clinical judgement: The role of physician networks

76.6 billion. Information technology implemented systematically has the potential to significantly reduce medication errors that result in adverse drug events (ADEs). OBJECTIVE To develop a computer simulation model that can be used to evaluate the effectiveness of information technology applications designed to detect and prevent medication errors that result in adverse drug effects. METHODS A computer simulation model was constructed representing the medication delivery system in a hospital. STELLA, a continuous simulation software package, was used to construct the model. Parameters of the model were estimated from a study of prescription errors on two hospital medical/surgical units and used in the baseline simulation. Five prevention strategies were simulated based on information obtained from the literature. RESULTS The model simulates the four stages of the medication delivery system: prescribing, transcribing, dispensing, and administering drugs. We simulated interventions that have been demonstrated in prior studies to decrease error rates. The results suggest that an integrated medication delivery system can save up to 1,226 days of excess hospitalization and

Recurrent Postictal Pulmonary Edema: A Case Report and Review of the Literature

1.4 million in associated costs annually in a large hospital. The results of the analyses regarding the effects of the interventions on the additional hospital costs associated with ADEs are somewhat sensitive to the distribution of errors in the hospital, more sensitive to the costs of an ADE, and most sensitive to the proportion of medication errors resulting in ADEs. CONCLUSIONS The results suggest that clinical information systems are potentially a cost-effective means of preventing ADEs in hospitals and demonstrate the importance of viewing medication errors from a systems perspective. Prevention efforts that focus on a single stage of the process had limited impact on the overall error rate. This study suggests that system-wide changes to the medication delivery system are required to drastically reduce mediation errors that may result in ADEs in a hospital setting.

Creating a New Paradigm for CME: Seizing Opportunities within the Health Care Revolution.

In order to study the relationship between physician networks and utilization of a computer-based hospital information system (HIS), blockmodel analysis and multidimensional scaling were used to analyze and spatially represent the network of professional relations among 24 physicians in a private group practice. A blockmodel analysis of patient referrals, consultations, discussions, and on-call coverage identified four groups of physicians who share common locations and perform similar roles within the network. Investigation of the shared attributes of these groups supports this relational structure. The results suggest that the center-periphery model of diffusion of new ideas among professionals may be too simplistic. Instead, the communication network may involve multiple central cohesive subgroups of physicians who differentially initiate patient referrals and consultations with physicians in other subgroups. Network location was found to have a significant effect on the adoption and utilization of the HIS independently of background and practice characteristics of physicians. The results also suggest that adoption of an innovation and its implementation or utilization may involve separate processes that need to be differentiated in future research.

Why Doctors Don’t Use Computers: Some Empirical Findings

Summary: A 37‐year‐old woman with a post‐traumatic seizure disorder had four well‐documented episodes of postical acute pulmonary edema and respiratory failure. Subtherapeutic blood concentrations of phenytoin were documented on each admission. Each episode followed one or more grand mal seizures and was characterized by the development of diffuse nodular‐appearing alveolar infiltrates, tachypnea, and severe hypoxemia that rapidly resolved with supportive therapy. There was no evidence of gastric acid aspiration, acute lung infectión, or underlying heart or lung disease. To determine the frequency of postictal pulmonary edema in our institution, we reviewed the clinical records and chest roentgenograms of 45 consecutive patients who were admitted to our emergency room following a well‐documented grand mal seizure. Only one patient (described in this report) had chest roentgenographic evidence of pulmonary edema. A review of the English literature revealed only 11 reported cases of postictal pulmonary edema since 1965 and a total of 42 episodes in 27 patients since 1908. There were no clearly documented cases of postical pulmonary edema following electroconvulsive therapy in 18 published reports totaling more than 38,000 subjects. Our findings suggest that while postictal pulmonary edema may occur repeatedly in the same patient, the overall frequency of this complication is low.

Modeling the Costs and Outcomes of Cardiovascular Surgery

When most people in health care think of CME, they think of a large room full of physicians who have taken time off from their busy practices to listen to a series of speakers who lecture to them about the most recent advances in their respective fields. The information presented may or may not be relevant to the practice circumstances of members of the audience. And, even if it is, it may not be in a form that can be readily applied in practice. Almost all contemporary CME takes place in this way.

Physician Communication Networks and the Adoption and Utilization of Computer Applications in Medicine

The attitudes of 148 medical students, 141 residents, and 644 practising physicians towards computer applications in medicine were studied. The results indicate that physicians recognize the potential of computers to improve patient care, but are concerned about the possibility of increased governmental and hospital control, threats to privacy, and legal and ethical problems. In general, all three groups are uncertain as to the potential effects of computers on their traditional professional role and on the organization of practice. Practising physicians, however, express more concern about these potential effects of computers than do medical students and residents. While attitudes appear to be somewhat independent of prior computer experience, they significantly affect the extent to which physicians use a computer-based hospital information system. This may be a major reason for the slow introduction of clinical computer systems.

Serum angiotensin converting enzyme activity in patients with psoriasis

Coronary artery bypass graft (CABG) operations consume more health care resources than any other single procedure. The objective of this study was to develop a computer simulation model that can be used to predict costs and patient outcomes of CABG surgery. The analysis is based on a systems dynamic model developed using STELLA software. Two sets of data from Medicare patients who underwent CABG operations at Methodist Hospital of Indiana were used to construct and validate the model. The model predictions of length of hospital stay, use of specialists in caring for patients, costs and postoperative functional status are reasonably close to actual data on patients who underwent CABG surgery. The analysis indicates the most important factors affecting costs and outcomes are gender, age, whether or not the surgery is a reoperation and whether the patient experiences postoperative complications. The model can be used to predict costs and outcomes for a patient population from a small set of preoperative characteristics (i.e., age, gender, DRG, whether the surgery is a reoperation, and the patients operative status). A second potential use of the model is to answer clinical questions such as do the costs and risks of CABG operations outweigh the benefits for patients with certain risk factors.

Applying the Theory of Planned Behavior to Explore the Relation Between Smoke-Free Air Laws and Quitting Intentions

This study demonstrates a methodological technique that can be used to specify the structure of the informal organization of medical practice and its effect on the practice behavior of physicians. This approach uses routinely collected clinical data to construct and analyze consultation networks among physicians who share a common practice setting—in the current study, hospital services. The focus of the analysis is on the identification of structurally equivalent groups of physicians who share similar consultation patterns with their colleagues, the nature of relationships among and between groups of physicians, and the effects of network structure on practice behavior, specifically, the adoption and utilization of a hospital information system. Results of the analysis of data from orthopaedic surgery, general surgery, and family practice are reported. The findings suggest that the physician’s position in the consultation network significantly influences rates of adoption and utilization of new computer technology.

Cost–Benefit Analysis of Home Blood Pressure Monitoring in Hypertension Diagnosis and Treatment: An Insurer Perspective

Serum angiotensin converting enzyme activity is frequently increased in patients with active sarcoidosis. In spite of a reported association between sarcoidosis and psoriasis, serum angiotensin converting enzyme activities have not been reported for patients with psoriasis. We found the mean (SD) angiotensin-converting enzyme activity for 51 healthy subjects was 18.6 (5.8) kU/l, but for 52 patients with psoriasis without coexisting sarcoidosis, it was 28.3 (6.7) kU/l. There is a significant difference between these means (p less than 0.01). Forty-two percent (22/52) of the psoriasis patients had an increased serum angiotensin converting activity. Other diseases sometimes associated with an increased serum angiotensin converting enzyme activity were excluded as possible causes of a elevated activity in our patients with psoriasis. We conclude that almost half of the patients with psoriasis will have an elevated serum angiotensin converting enzyme activity, even when coexisting sarcoidosis is absent.