Reduced Clostridium difficile Tests and Laboratory-Identified Events With a Computerized Clinical Decision Support Tool and Financial Incentive.

We hypothesized that a computerized clinical decision support tool for Clostridium difficile testing would reduce unnecessary inpatient tests, resulting in fewer laboratory-identified events. Census-adjusted interrupted time-series analyses demonstrated significant reductions of 41% fewer tests and 31% fewer hospital-onset C. difficile infection laboratory-identified events following this intervention.

Tailored Educational Approaches for Consumer Health: A Model to Address Health Promotion in an Era of Personalized Medicine.

Purpose: To develop a model, based on market segmentation, to improve the quality and efficiency of health promotion materials and programs.

Design: Market segmentation to create segments (groups) based on a cross-sectional questionnaire measuring individual characteristics and preferences for health information. Educational and delivery recommendations developed for each group.

Effect of pooled comparative information on judgments of quality.

Quality assessment is the focus of many health care initiatives. Yet it is not well understood how the type of information used in decision support tools to enable judgments of quality based on data impacts the accuracy, consistency and reliability of judgments made by physicians. Comparative pooled information could allow physicians to judge the quality of their practice by making comparisons to other practices or other specific populations of patients.

Clinical decision support: progress and opportunities.

In 2005, the American Medical Informatics Association undertook a set of activities relating to clinical decision support (CDS), with support from the office of the national coordinator and the Agency for Healthcare Research and Quality. They culminated in the release of the roadmap for national action on CDS in 2006. This article assesses progress toward the short-term goals within the roadmap, and recommends activities to continue to improve CDS adoption throughout the United States.

Providing palliative care in the ambulatory care setting.

Palliative care that provides specialized attention to pain and symptom management is important for patients with cancer. Palliative care aims to reduce pain and other symptoms through an interdisciplinary approach involving physicians, nurses, social workers, and other members of the healthcare team. Families are included in care planning.

SUPPORTING PHYSICIANS' PRACTICE-BASED LEARNING AND IMPROVEMENT (PBLI) AND QUALITY IMPROVEMENT THROUGH EXPLORATION OF POPULATION-BASED MEDICAL DATA.

Participating in self-assessment activities may stimulate improvement in practice behaviors. However, it is unclear how best to support the development of self-assessment skills, particularly in the health care domain. Exploration of population-based data is one method to enable health care providers to identify deficiencies in overall practice behavior that can motivate quality improvement initiatives.

Formulary access using a PDA-based drug reference tool: does it affect prescribing behavior?

We assessed the association between formulary access via a handheld drug reference tool and utilization of generic (Tier 1) and non-generic, non-formulary (Tier 3) medications. In a retrospective before-after study of physician prescribing behavior for patients in a large, national health plan, physicians with formulary access using Epocrates(TM) showed smaller (0.5%) increases in Tier 3 prescribing over time compared to physicians without such access.

Changing conversations: teaching safety and quality in residency training.

Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia.

Development of a Web-based resident profiling tool to support training in practice-based learning and improvement.

Multiple factors are driving residency programs to explicitly address practice-based learning and improvement (PBLI), yet few information systems exist to facilitate such training. We developed, implemented, and evaluated a Web-based tool that provides Internal Medicine residents at the University of Virginia Health System with population-based reports about their ambulatory clinical experiences. Residents use Systems and Practice Analysis for Resident Competencies (SPARC) to identify potential areas for practice improvement.

The development of health care data warehouses to support data mining.

Clinical data warehouses offer tremendous benefits as a foundation for data mining. By serving as a source for comprehensive clinical and demographic information on large patient populations, they streamline knowledge discovery efforts by providing standard and efficient mechanisms to replace time-consuming and expensive original data collection, organization, and processing. Building effective data warehouses requires knowledge of and attention to key issues in database design, data acquisition and processing, and data access and security.

Electronic health records: high-quality electronic data for higher-quality clinical research.

In the decades prior to the introduction of electronic health records (EHRs), the best source of electronic information to support clinical research was claims data. The use of claims data in research has been criticised for capturing only demographics, diagnoses and procedures recorded for billing purposes that may not fully reflect the patient's condition. Many important details of the patient's clinical status are not recorded.

Tailored Educational Approaches for Consumer Health (TEACH): a model system for addressing health communication.

The Consumer Health Education Institute (CHEDI) has developed a model system to improve the quality and effectiveness of patient education and health communication. Through assessment of characteristics and preferences, segmentation into groups and matching with the appropriate materials, we have demonstrated that patients and health consumers have different health information needs and preferences which show promise as a basis for selecting or designing the most appropriate materials or programs.

Impact of a Web-based diagnosis reminder system on errors of diagnosis.

A large number of medical errors can be attributed to errors in diagnosis. A diagnosis reminder system such as Isabel may lessen the risk of diagnostic error by providing a checklist of possible diagnoses. For this project, resident physicians used Isabel to work through a set of six simulated patient cases.

Cost of Gram-negative resistance.

Objective: It is unclear that infections with Gram-negative rods resistant to at least one major class of antibiotics (rGNR) have a greater effect on patient morbidity than infections caused by sensitive strains (sGNR). We wished to test the hypothesis that rGNR infections are associated with higher resource utilization.

Design: Retrospective observational cohort study of prospectively collected data.

Updated review of blood culture contamination.

Blood culture contamination represents an ongoing source of frustration for clinicians and microbiologists alike. Ambiguous culture results often lead to diagnostic uncertainty in clinical management and are associated with increased health care costs due to unnecessary treatment and testing. A variety of strategies have been investigated and employed to decrease contamination rates.

Data mining and clinical data repositories: Insights from a 667,000 patient data set.

Clinical repositories containing large amounts of biological, clinical, and administrative data are increasingly becoming available as health care systems integrate patient information for research and utilization objectives. To investigate the potential value of searching these databases for novel insights, we applied a new data mining approach, HealthMiner, to a large cohort of 667,000 inpatient and outpatient digital records from an academic medical system. HealthMiner approaches knowledge discovery using three unsupervised methods: CliniMiner, Predictive Analysis, and Pattern Discovery.

Present-at-admission diagnoses improve mortality risk adjustment and allow more accurate assessment of the relationship between volume of lung cancer operations and mortality risk.

Background: Mortality risk adjustment is a key component of studies that examine the statistical relationship between hospital lung cancer operation volume and in-hospital mortality. Previous studies of this relationship have used different methods of adjusting for factors that influence mortality risk, but none have adjusted for differences in comorbid disease using only diagnoses identified as present-at-admission.

Methods: This study uses adjustments for conditions identified as present-at-admission to examine the statistical relationship between the volume of lung cancer operations and mortality among 14,456 California hospital patients, and compares these results to other methods of risk adjustment similar to those used in previous studies.

Comorbid disease and the effect of race and ethnicity on in-hospital mortality from aspiration pneumonia.

Background: Racial and ethnic disparities in mortality have been demonstrated in several diseases. African Americans are hospitalized at a significantly higher rate than whites for aspiration pneumonia; however, no studies have investigated racial and ethnic disparities in mortality in this population.

Objective: To assess the independent effect of race and ethnicity on in-hospital mortality among aspiration pneumonia discharges while comprehensively controlling for comorbid diseases, and to assess whether the prevalence and effects of comorbid illness differed across racial and ethnic categories.

The effect of physician feedback and an action checklist on diabetes care measures.

The objective was to evaluate whether physician feedback accompanied by an action checklist improved diabetes care process measures. Eighty-three physicians in an academic general medicine clinic were provided a single feedback report on the most recent date and result of diabetes care measures (glycosylated hemoglobin [A1c], urine microalbumin, serum creatinine, lipid levels, retinal examination) as well as recent diabetes medication refills with calculated dosing and adherence on 789 patients. An educational session regarding the feedback and adherence information was provided.

Hospital discharge abstract data on comorbidity improved the prediction of death among patients hospitalized with aspiration pneumonia.

Objective: To use diagnoses reported as present at admission in California hospital discharge abstract data to identify categories of comorbid disease and conditions related to aspiration pneumonia and to assess their association with hospital mortality.

Study Design And Setting: The study population included all persons hospitalized in California from 1996 through 1999, with a principal diagnosis of aspiration pneumonia. Present at admission diagnoses representing comorbid diseases were separated from conditions closely related to aspiration pneumonia by a physician panel through a computer supported Delphi process.

Improving quality measurement using multiple data sources.

We calculated a sample of AHRQ Quality and Patient Safety Indicators for UVa hospitalized patients over a 3 year period using diagnoses and procedure codes from two different billing systems. Significant differences in results were observed suggesting that quality indicators calculated from hospital billing sources alone may be understated.

Mapping from a clinical data warehouse to the HL7 Reference Information Model.

Large-scale data integration efforts to support clinical and biologic research are greatly facilitated by the adoption of standards for the representation and exchange of data. As part of a larger project to design the necessary architecture for multi-institutional sharing of disparate biomedical data, we explored the potential of the HL7 Reference Information Model (RIM) for representing the data stored in a local academic clinical data warehouse. A necessary first step in information exchange with such a warehouse is the development and utilization of tools for transforming between local data schemas and standards-based conceptual data models.

A cross-site qualitative study of physician order entry.

Objective: To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals.

Design: A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data.