Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study.

Background: Full sharing of the electronic health record with patients has been identified as an important opportunity to engage patients in their health and health care. The My HealtheVet Pilot, the initial personal health record of the US Department of Veterans Affairs, allowed patients and their delegates to view and download content in their electronic health record, including clinical notes, laboratory tests, and imaging reports.

Objective: A qualitative study with purposeful sampling sought to examine patients' views and experiences with reading their health records, including their clinical notes, online.

Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems.

Background: Clinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited research on the availability of various CDS tools across current electronic health record (EHR) systems.

Objective: To develop and validate a taxonomy of front-end CDS tools and to assess support for these tools in major commercial and internally developed EHRs.

Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records.

Background: We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria.

Governance for clinical decision support: case studies and recommended practices from leading institutions.

Objective: Clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety; however, effective implementation of CDS requires effective clinical and technical governance structures. The authors sought to determine the range and variety of these governance structures and identify a set of recommended practices through observational study.

Design: Three site visits were conducted at institutions across the USA to learn about CDS capabilities and processes from clinical, technical, and organizational perspectives.

Effect of the implementation of an enterprise-wide Electronic Health Record on productivity in the Veterans Health Administration.

Since 1995, the Veterans Health Administration (VHA) has had an ongoing process of systems improvement that has led to dramatic improvement in the quality of care delivered. A major component of the redesign of the VHA has been the creation of a fully developed enterprise-wide Electronic Health Record (EHR). VHA's Health Information Technology was developed in a collaborative fashion between local clinical champions and central software engineers.

Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' Computerized Patient Record System.

Objective: To measure critical order check override rates in VA Puget Sound Health Care System's computerized practitioner order entry (CPOE) system and to compare 2006 results to a similar 2001 study.

Design: Analysis of ordering and order check data gathered by a post-hoc logging program. Use of Pearson's chi-square contingency table test comparing results from this study and the earlier study.

Reasons provided by prescribers when overriding drug-drug interaction alerts.

Objectives: To investigate prescribers' rationales for overriding drug-drug interaction (DDI) alerts and to determine whether these reasons were helpful to pharmacists as a part of prescription order verification.

Study Design: An observational retrospective database analysis was conducted using override reasons derived from a computerized system at 6 Veterans Affairs medical centers.

Methods: Data on DDI alerts (for interactions designated as "critical" and "significant") were obtained from ambulatory care pharmacy records from July 1, 2003, to June 30, 2004.

Practitioners' views on computerized drug-drug interaction alerts in the VA system.

Objectives: To assess Veterans Affairs (VA) prescribers' and pharmacists' opinions about computer-generated drug-drug interaction (DDI) alerts and obtain suggestions for improving DDI alerts.

Design: A mail survey of 725 prescribers and 142 pharmacists from seven VA medical centers across the United States.

Measurements: A questionnaire asked respondents about their sources of drug and DDI information, satisfaction with the combined inpatient and outpatient computerized prescriber order entry (CPOE) system, attitude toward DDI alerts, and suggestions for improving DDI alerts.

Approach for analysis of order check overrides in a computerized practitioner order entry system.

While it has been established that electronic order entry systems can prevent transcription errors and check orders for severe drug allergies and interactions, continuous monitoring of the effectiveness of order checks is important. The goal of this study is to examine the rate at which high severity order checks generated in the electronic medical record at VA Puget Sound are overridden by clinicians. We compare our results to those of a previous study that found high override rates for Critical Drug Inter-action and Allergy-Drug Interaction order check categories.

Telemedicine for delivery of health care in Parkinson's disease.

We have used telemedicine at the Seattle Veterans Administration Medical Center to deliver follow-up care to patients with Parkinson's disease (PD). Patients were located at eight facilities which were 67-2400 km from the medical centre. Each facility had videoconferencing equipment (connected by Internet Protocol at 384 kbit/s), and computer terminals that could access the patient's electronic medical record.

Case-mix adjusting performance measures in a veteran population: pharmacy- and diagnosis-based approaches.

Objective: To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures.

Data Sources/study Setting: The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N = 126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse.

Characteristics and override rates of order checks in a practitioner order entry system.

Order checks are important error prevention tools when used in conjunction with practitioner order entry systems. We studied characteristics of order checks generated in a sample of consecutively entered orders during a 4 week period in an electronic medical record at VA Puget Sound. We found that in the 42,641 orders where an order check could potentially be generated, 11% generated at least one order check and many generated more than one order check.

Outpatient nursing case management for cardiovascular disease.

Case management has been an effective treatment model for maintaining costs while preserving quality of care for vulnerable populations who are frequent care users. Nursing case management has been effective in improving health outcomes in chronically ill populations. Specifically, nurse practitioner care has been as effective, and in some areas, more effective in managing chronic health problems of patients than care provided by physicians.

Comparison of three quality of life instruments in stable angina pectoris: Seattle Angina Questionnaire, Short Form Health Survey (SF-36), and Quality of Life Index-Cardiac Version III.

Three instruments for the assessment of quality of life, the Seattle Angina Questionnaire (SAQ), the Short Form Health Survey (SF-36), and the Quality of Life Index-Cardiac Version III (QLI) were administered to 107 patients with stable angina pectoris in a longitudinal randomized trial comparing the use of alternative anginal medications in the management of chronic stable angina pectoris. This study demonstrated that differences in angina severity as measured by the Canadian Cardiovascular Society Classification (CCSC) were related to each of the SAQ subscales, to selected subscales of the SF-36, but not to the QLI. All quality of life (QOL) instruments demonstrated acceptable test-retest reliability when administered over a 2-week interval.

Measurement of the AH and HV interval and His bundle duration: interobserver and intraobserver variation.

Conduction system intervals measured during intracardiac electrophysiologic testing influence clinical decisions. To evaluate measurement reliability, interobserver and intraobserver variation for AH, HV, and His bundle duration measurements from 50 patients were evaluated. The square of the correlation coefficient (r2) was used as the index for measurement reliability.

Experience with coeliac axis compression syndrome.

Seven patients with "coeliac axis compression syndrome" are reported. Five were treated surgically, but only two did well. A survey of 200 healthy adults showed epigastric bruits in 6.