Clinical decision support capabilities of commercially-available clinical information systems.

Background: The most effective decision support systems are integrated with clinical information systems, such as inpatient and outpatient electronic health records (EHRs) and computerized provider order entry (CPOE) systems. Purpose The goal of this project was to describe and quantify the results of a study of decision support capabilities in Certification Commission for Health Information Technology (CCHIT) certified electronic health record systems.

Methods: The authors conducted a series of interviews with representatives of nine commercially available clinical information systems, evaluating their capabilities against 42 different clinical decision support features.

A set of preliminary standards recommended for achieving a national repository of clinical decision support interventions.

We are investigating the development, implementation and evaluation of clinical decision support (CDS) projects to advance our understanding of how best to incorporate these interventions into the delivery of healthcare. Our overall goal is to explore how the translation of clinical knowledge into CDS and its incorporation into practice can be routinely achieved to improve the quality of healthcare delivered in the U.S.

Persistent paper: the myth of "going paperless".

How does paper usage change following the introduction of Computerized Physician Order Entry and the Electronic Medical Record (EMR/CPOE)? To answer that question we analyzed data collected from fourteen sites across the U.S. We found paper in widespread use in all institutions we studied.

Computerized provider order entry adoption: implications for clinical workflow.

Objective: To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems.

Methods: We analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow.

A scientific collaboration tool built on the facebook platform.

We describe an application ("Medline Publications")written for the Facebook platform that allows users to maintain and publish a list of their own Medline-indexed publications, as well as easily access their contacts lists. The system is semi-automatic in that it interfaces directly with the National Library of Medicine's PubMed database to find and retrieve citation data. Furthermore, the system has the capability to present the user with sets of other users with similar publication profiles.

A rapid assessment process for clinical informatics interventions.

Informatics interventions generally take place in rapidly changing settings where many variables are outside the control of the evaluator. Assessment must be timely so that feedback can instigate modification of the intervention. Adapting a methodology from international health and epidemiology, we have developed and refined a Rapid Assessment Process (RAP) for informatics while conducting a study of clinical decision support (CDS) in community hospitals.

Field evaluation of commercial Computerized Provider Order Entry systems in community hospitals.

Computerized Provider Order Entry (CPOE) is an important component of the electronic health record, but there has been some difficulty with user acceptance, and this is often due to poor computer interface usability which disrupts clinician workflow. This qualitative research employed usability engineering methods to study community hospital physicians using commercial CPOE systems while in a naturalistic context. Numerous usability problems were uncovered with this effective technique.

A socio-technical model of health information technology-related e-iatrogenesis.

When encouraging reports of Health Information Technology successes are coupled with recent recommendations from the Institute of Medicine that healthcare organizations adopt state-of-the-art clinical information systems (ClSs) as a key component of the solution to care-quality problems, the pressure on hospitals and physician practices to implement CISs has never been greater. Unfortunately, few hospitals or physician practices have the organizational, IT, or informatics resources in place to achieve these goals. Recently there have been several reports that have begun to raise questions about the safety of CISs themselves.

Creating and sharing clinical decision support content with Web 2.0: Issues and examples.

Clinical decision support is a powerful tool for improving healthcare quality and patient safety. However, developing a comprehensive package of decision support interventions is costly and difficult. If used well, Web 2.

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.

Objective: To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE).

Methods: Using a mixed methods approach, we identified and categorized into nine types 380 examples of the unintended consequences of CPOE gleaned from fieldwork data and a conference of experts. We then conducted a national survey in the U.

SANDS: an architecture for clinical decision support in a National Health Information Network.

A new architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support) is introduced and its performance evaluated. The architecture provides a method for performing clinical decision support across a network, as in a health information exchange. Using the prototype we demonstrated that, first, a number of useful types of decision support can be carried out using our architecture; and, second, that the architecture exhibits desirable reliability and performance characteristics.

Recommendations for monitoring and evaluation of in-patient Computer-based Provider Order Entry systems: results of a Delphi survey.

A survey of 20 clinical informaticists with experience in implementing Computer-based Provider Order Entry (CPOE) systems revealed the lack of easily accessible measurements of success. Using a Delphi approach, the authors, together with a group of CPOE experts, selected eight key CPOE-related measures to assess system availability, use, benefits, and e-Iatrogenesis. We suggest collecting these measures on a widespread/national basis would be wise stewardship and result in tighter feedback about both clinician workflow and patient safety.

Recommendations for clinical decision support deployment: synthesis of a roundtable of medical directors of information systems.

Background: Ample evidence exists that clinical decision support (CDS) can improve clinician performance. Nevertheless, additional evidence demonstrates that clinicians still do not perform adequately in many instances. This suggests an ongoing need for implementation of CDS, in turn prompting development of a roadmap for national action regarding CDS.

Overdependence on technology: an unintended adverse consequence of computerized provider order entry.

Computerized provider order entry (CPOE) and other clinical information systems can help reduce medical errors, promote practice standardization, and improve the quality of patient care. However, implementing these systems can result in unintended adverse consequences. Our multidisciplinary team used qualitative methods to gather and analyze data describing unintended adverse consequences related to CPOE adoption and use.

Some unintended consequences of clinical decision support systems.

Clinical decision support systems (CDS) coupled with computerized physician/provider order entry (CPOE) can improve the quality of patient care and the efficiency of hospital operations. However, they can also produce unintended consequences. Using qualitative methods, a multidisciplinary team gathered and analyzed data about the unintended consequences of CPOE, identifying nine types, and found that CDS-generated unintended consequences appeared among all types.

A framework and model for evaluating clinical decision support architectures.

In this paper, we develop a four-phase model for evaluating architectures for clinical decision support that focuses on: defining a set of desirable features for a decision support architecture; building a proof-of-concept prototype; demonstrating that the architecture is useful by showing that it can be integrated with existing decision support systems and comparing its coverage to that of other architectures. We apply this framework to several well-known decision support architectures, including Arden Syntax, GLIF, SEBASTIAN, and SAGE.

SANDS: a service-oriented architecture for clinical decision support in a National Health Information Network.

In this paper, we describe and evaluate a new distributed architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support), which leverages current health information exchange efforts and is based on the principles of a service-oriented architecture. The architecture allows disparate clinical information systems and clinical decision support systems to be seamlessly integrated over a network according to a set of interfaces and protocols described in this paper. The architecture described is fully defined and developed, and six use cases have been developed and tested using a prototype electronic health record which links to one of the existing prototype National Health Information Networks (NHIN): drug interaction checking, syndromic surveillance, diagnostic decision support, inappropriate prescribing in older adults, information at the point of care and a simple personal health record.

Prediction model for estimating the survival benefit of adjuvant radiotherapy for gallbladder cancer.

Purpose: The benefit of adjuvant radiotherapy (RT) for gallbladder cancer remains controversial because most published data are from small, single-institution studies. The purpose of this study was to construct a survival prediction model to enable individualized predictions of the net survival benefit of adjuvant RT for gallbladder cancer patients based on specific tumor and patient characteristics.

Methods: A multivariate Cox proportional hazards model was constructed using data from 4,180 patients with resected gallbladder cancer diagnosed from 1988 to 2003 from the Surveillance, Epidemiology, and End Results database.

A four-phase model of the evolution of clinical decision support architectures.

Background: A large body of evidence over many years suggests that clinical decision support systems can be helpful in improving both clinical outcomes and adherence to evidence-based guidelines. However, to this day, clinical decision support systems are not widely used outside of a small number of sites. One reason why decision support systems are not widely used is the relative difficulty of integrating such systems into clinical workflows and computer systems.

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.

Assessing the anticipated consequences of Computer-based Provider Order Entry at three community hospitals using an open-ended, semi-structured survey instrument.

Objective: To determine what "average" clinicians in organizations that were about to implement Computer-based Provider Order Entry (CPOE) were expecting to occur, we conducted an open-ended, semi-structured survey at three community hospitals.

Methods: We created an open-ended, semi-structured, interview survey template that we customized for each organization. This interview-based survey was designed to be administered orally to clinicians and take approximately 5 min to complete, although clinicians were allowed to discuss as many advantages or disadvantages of the impending system roll-out as they wanted to.

Conditional survival in gastric cancer: a SEER database analysis.

Background: Gastric cancer survival is typically reported in terms of survival from the time of diagnosis. Conditional survival is a more relevant measure of prognosis for patients who have already survived 1 or more years since diagnosis.

Methods: Using the Surveillance, Epidemiology, and End Results (SEER 17) database from the National Cancer Institute, we analyzed data from 20 018 gastric cancer patients diagnosed between 1988 and 1998.

A survey of U.S.A. acute care hospitals' computer-based provider order entry system infusion levels.

We developed and fielded a survey to help clinical information system designers, developers, and implementers better understand the infusion level, or the extent and sophistication of CPOE feature availability and use by clinicians within acute care hospitals across the United States of America. In the 176 responding hospitals, we found that CPOE had been in place a median of 5 years and that the median percentage of orders entered electronically was 90.5%.

Exploring the unintended consequences of computerized physician order entry.

This paper summarizes the foci, activities, methods, and results of a three-year research project. Using a mixed methods approach, the Physician Order Entry Team has identified and categorized the unintended consequences of computerized physician order entry (CPOE). After analyzing 380 examples of unintended adverse consequences, the team described in detail nine major types and conducted a national survey in the U.