User interface accelerators for clinical documentation in Smart Form.

We have deployed a number of user interface accelerators within the text editor of a documentation-based clinical decision support application. These accelerators enhance the process of documenting a visit and promote closer integration of actionable decision support into the documentation workflow.

Hybrid representation of hierarchical structures in point-of-care coded data capture platform.

Capturing structured clinical documentation remains a central challenge in clinical informatics. A solution which represented highly hierarchical data in a relational structure exhibited degradation in performance as complexity of hierarchies grew. To ameliorate the problem, we devised a hybrid approach whereby we commit a precompiled XML representation of hierarchical data as well as individual records to a relational database.

Can a "Smart Form" increase physicians' satisfactions with managing patient health behavior risks? Results of a physician satisfaction survey.

Results of a pilot study suggest that the Coronary Artery Disease and Diabetes Mellitus Smart Form may help clinicians in managing diet and exercise in patients with chronic diseases by making patient handouts and exercise prescriptions readily available at the time of the visit.

The Acute Respiratory Infection Quality Dashboard: a performance measurement reporting tool in an electronic health record.

Quality reporting tools, integrated with electronic health records, can help clinicians understand performance, manage populations, and improve quality. The Acute Respiratory Infection Quality Dashboard (ARI QD) for LMR users is a secure web report for performance measurement of an acute condition delivered through a central data warehouse and custom-built reporting tool. Pilot evaluation of the ARI QD indicates that clinicians prefer a quality report that combines not only structured data regarding diagnosis and antibiotic prescribing rates entered into EHRs but one that also shows billing data.

The coronary artery disease quality dashboard: a chronic care disease management tool in an electronic health record.

Quality reporting tools, integrated with ambulatory electronic health records (EHRs), may help clinicians understand performance, manage populations, and improve quality. The Coronary Artery Disease Quality Dash board (CAD QD) is a secure web report for performance measurement of a chronic care condition delivered through a central data warehouse and custom-built reporting tool. Pilot evaluation of the CAD Quality Dash board indicates that clinicians prefer a quality report that combines not only structured data from EHRs but one that facilitates actions to be taken on individual patients or on a population, i.

Patient review of selected electronic health record data improves visit experience.

Patients are increasingly empowered, informed and active participants in their healthcare. Patients at Partners Healthcare in Boston, MA utilized a web- based portal, Patient Gateway, to submit pre-visit health status information through a journal to their provider. Results of a patient survey indicate that such tools have the potential to improve communication and patient satisfaction, and that the content of information influences the patients visit experience.

Patient care experience enhanced by use of online journals.

Patient involvement in their healthcare has increased with the use of electronic patient portals. The ability to submit updates to select sections of their medical record prior to a visit is shown to be effective in enhancing patients care experience. Those patients who discussed the updates with their physician at the visit reported an even more positive response.

Cost of interconnecting health information exchanges to form a national network.

Despite the demonstrated need for a national health information network (NHIN), there has been little progress in turning this need into reality beyond limited local demonstrations. One barrier is the lack of information evaluating the potential costs of connecting these local networks to form a national network. The Center for Information Technology Leadership (CITL), in conjunction with national experts, developed assumptions around the components needed to develop the NHIN.

Clinical decision support to improve antibiotic prescribing for acute respiratory infections: results of a pilot study.

Acute Respiratory Infections (ARIs) are the number one reason for antibiotic prescribing in the United States, and much antibiotic prescribing for ARIs is inappropriate. We designed an electronic health record-integrated, documentation-based clinical decision support system for the care of patients with ARIs, the ARI Smart Form. To evaluate the ARI Smart Form and assess the feasibility of performing a larger trial, we conducted a pilot study with 10 clinicians who used the ARI Smart Form with 26 patients.

A framework and approach for assessing the value of personal health records (PHRs).

Personal Health Records (PHRs) are a rapidly expanding area of medical informatics due to the belief that they may improve health care delivery and control costs of care. The PHRs in use or in development today support a myriad of different functions, and consequently offer different value propositions. A comprehensive value analysis of PHRs has never been conducted; such analysis is needed to identify those PHR functions that yield the greatest value to PHR stakeholders.

The value of provider-to-provider telehealth.

Telehealth has great potential to improve access to care, but its adoption in routine healthcare has been slow. The lack of clarity about the value of telehealth implementations has been one reason cited for this slow adoption. The Center for Information Technology Leadership has examined the value of telehealth encounters in which there is a provider both with the patient and at a distance from the patient.

Sleep during the Antarctic winter: preliminary observations on changing the spectral composition of artificial light.

Antarctic Base personnel live for 3 months in winter with no natural sunlight. This project compared sleep, by actigraphy, during periods of increased exposure to white light or blue enriched light in 2003. The primary aim was to help define the optimum spectral composition and intensity of artificial environmental light.

The value proposition in the widespread use of telehealth.

Telehealth has great potential to improve access to care but its adoption in routine health care has been slow. The lack of clarity about the value of telehealth implementations has been one reason cited for this slow adoption. The Center for Information Technology Leadership has examined the value of telehealth encounters in which there is a provider both with the patient and at a distance from the patient.

"Smart Forms" in an Electronic Medical Record: documentation-based clinical decision support to improve disease management.

Clinical decision support systems (CDSS) integrated within Electronic Medical Records (EMR) hold the promise of improving healthcare quality. To date the effectiveness of CDSS has been less than expected, especially concerning the ambulatory management of chronic diseases. This is due, in part, to the fact that clinicians do not use CDSS fully.

Measuring melatonin in humans.

Study Objectives: To provide guidelines for collecting and analyzing urinary, salivary, and plasma melatonin, thereby assisting clinicians and researchers in determining which method of measuring melatonin is most appropriate for their particular needs and facilitating the comparison of data between laboratories.

Methods: A modified RAND process was utilized to derive recommendations for methods of measuring melatonin in humans.

Results: Consensus-based guidelines are presented for collecting and analyzing melatonin for studies that are conducted in the natural living environment, the clinical setting, and in-patient research facilities under controlled conditions.

Grand challenges in clinical decision support.

There is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and maintaining all types of clinical decision support capabilities for clinicians, patients and consumers. Using an iterative, consensus-building process we identified a rank-ordered list of the top 10 grand challenges in clinical decision support. This list was created to educate and inspire researchers, developers, funders, and policy-makers.

The economic benefits of health information exchange interoperability for Australia.

Objective: To estimate costs and benefits for Australia of implementing health information exchange interoperability among health care providers and other health care stakeholders.

Design: A cost-benefit model considering four levels of interoperability (Level 1, paper based; Level 2, machine transportable; Level 3, machine readable; and Level 4, machine interpretable) was developed for Government-funded health services, then validated by expert review.

Results: Roll-out costs for Level 3 and Level 4 interoperability were projected to be $21.

Empowering patients to improve the quality of their care: design and implementation of a shared health maintenance module in a US integrated healthcare delivery network.

We describe a health maintenance module within a personal health record designed to improve the quality of routine preventive care for patients in a large integrated healthcare delivery network. This module allows patients and their providers to share an online medical record and decision support tools. Our preliminary results indicate that this approach is well-accepted by patients and their providers and has significant potential to facilitate patient-provider communication and improve the quality of routine health maintenance care.

Sharing electronic laboratory results in a patient portal--a feasibility pilot.

Surveys of patients consistently demonstrate a very strong interest in having secure electronic access to their own laboratory test results. In recent years, a number of health care providers and lab service centers have offered this capability, which now extends to millions of patients in the United States. Yet, little has been published on the methods of making lab results available.

Disturbances in melatonin and core body temperature circadian rhythms after minimal invasive surgery.

Background: Sleep disturbances, fatigue and reduced general well-being frequently occur after minimal invasive surgery. The circadian rhythms of melatonin and core body temperature are central to the regulation of normal sleep. The aim of this study was to assess changes in these circadian rhythms after laparoscopic cholecystectomy.

Impact of sleep and circadian disturbances in urinary 6-sulphatoxymelatonin levels, on cognitive function after major surgery.

Sleep and circadian disturbances may underlie cognitive dysfunction after major surgery. The aim of this study was to examine the association between sleep and circadian disturbances (as assessed by changes in the melatonin rhythm) and postoperative cognitive dysfunction (POCD). We measured subjective and objective sleep quality, excretion of the major metabolite of melatonin, 6-sulphatoxymelatonin (aMT6s) in urine and cognitive function before and 4 days after major abdominal surgery in 36 patients.

An optimized automated assay for determination of metabolic stability using hepatocytes: assay validation, variance component analysis, and in vivo relevance.

Screening of new chemical entities for metabolic stability using hepatocytes is routinely used in drug discovery. To enhance compound throughput, an optimized automated microassay for determination of intrinsic clearance was developed. Dulbecco's modified Eagle's medium, Hanks' balanced salt solution, and Leibovitz L-15 medium (L-15) were tested for their ability to maintain cell viability during incubation in 96-well plates.

Electronic health record use and the quality of ambulatory care in the United States.

Background: Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. We assessed the association between EHR use, as implemented, and the quality of ambulatory care in a nationally representative survey.

Methods: We performed a retrospective, cross-sectional analysis of visits in the 2003 and 2004 National Ambulatory Medical Care Survey.

The cost of information technology-enabled diabetes management.

As a result of the high cost of diabetes, an array of interventions for managing this disease has been developed. Estimating the cost of various approaches to diabetes disease management is critical to inform purchasing decisions. This review focuses on 5 provider- and payer-sponsored diabetes management approaches that use information technology (IT) and provides cost estimates for each approach based on a literature review and interviews with 38 provider practices, hospitals, payers, and vendors.

Robust circadian rhythm in heart rate and its variability: influence of exogenous melatonin and photoperiod.

Heart rate (HR) and heart rate variability (HRV) undergo marked fluctuations over the 24-h day. Although controversial, this 24-h rhythm is thought to be driven by the sleep-wake/rest-activity cycle as well as by endogenous circadian rhythmicity. We quantified the endogenous circadian rhythm of HR and HRV and investigated whether this rhythm can be shifted by repeated melatonin administration while exposed to an altered photoperiod.