Biomedical subjects

Adam Wilcox

Publications and source records attributed to Adam Wilcox.

10 recordsLinked to original sources

PubMed2007

Emergency department access to a longitudinal medical record.

Our goal is to assess how clinical information from previous visits is used in the emergency department. We used detailed user audit logs to measure access to different data types. We found that clinician-authored notes and laboratory and radiology data were used most often (common data types were used up to 5% to 20% of the time). Data were accessed less than half the time (up to 20% to 50%) even when the user was alerted to the presence of data. Our access rate indicates that health information exchange projects should be conservative in estimating how often shared data will be used and the wide breadth of data accessed indicates that although a clinical summary is likely to be useful, an ideal solution will supply a broad variety of data.

Emergency Service, Hospital↗

PubMed2007

Productivity enhancement for primary care providers using multicondition care management.

OBJECTIVE: To assess the impact of a multicondition care management system on primary care physician efficiency and productivity. STUDY DESIGN: Retrospective controlled repeated-measures design comparing physician productivity with the proportion of patients in the care management system. METHODS: The setting was primary care clinics in Intermountain Healthcare, a large integrated delivery network. The care management system consisted of a trained team with nurses as care managers and specialized information technology. We defined the use of the care management system as a proportion of referrals by the physician to the care manager. Clinic, physician, and patient panel demographics were used to adjust expected visit productivity and were included in a multivariate mixed model with repeated measures comprising work relative value units and system use. RESULTS: The productivity of 120 physicians in 7 intervention clinics and 14 control clinics was compared during 24 months. Clinic, physician, and patient panel characteristics exhibited similar characteristics, although patients in intervention clinics were less likely to be married. Adjusted work relative value units were 8% (range, 5%-12%) higher for intervention clinics vs control clinics. Additional annual revenue was estimated at 99,986 dollars per clinic. These additional revenues outweighed the estimated cost of the program of 92,077 dollars. CONCLUSIONS: Physician productivity increased when more than 2% of patients were seen by a care management team; the increased revenue in our market exceeded the cost of the program. Implications for the creation, structure, and reimbursement of such teams are discussed.

Adult↗

PubMed2006

A framework for information system usage in collaborative care.

UNLABELLED: Clinical information systems (CIS) can affect the quality of patient care. In this paper, we focus on CIS use in the collaborative treatment of chronic diseases. We have developed a framework to determine which CIS functions have general usefulness for improving patient outcomes. METHODS: We reviewed the use of clinical information systems within a collaborative care environment, identifying CIS functions important in chronic disease care. We grouped the functions into categories of access, best practices, and communication (ABC). Three independent raters selected the most important collaborative care related functions from the HL7 Electronic Health Record Systems functional model, and mapped the HL7 functions against the ABC categories. We then built a model of CIS use and tested it on data from a cohort of patients with chronic illnesses. RESULTS: Of the 133 HL7 elements in the ABC model, 60 (45%) were ranked as important for collaborative care by two reviewers. Agreement was moderate for importance (kappa=.20) but high for ABC categorization (kappa=.67). In our data tests, for the 1105 patients, access 4.4+/-6.5, best practices 0.8+/-1.6, and communication 2.9+/-4.5. CIS functions were used per episode of care. We were able to identify several key functions that may affect patient care. For example, certain CIS functions related to best practices were associated with higher clinician adherence to testing guidelines. DISCUSSION: This framework may be useful to assess and compare CIS systems for collaborative care. Future refinements of the model are discussed.

Chronic Disease↗

PubMed2006

Using discordance to improve classification in narrative clinical databases: an application to community-acquired pneumonia.

Data mining in electronic medical records may facilitate clinical research, but much of the structured data may be miscoded, incomplete, or non-specific. The exploitation of narrative data using natural language processing may help, although nesting, varying granularity, and repetition remain challenges. In a study of community-acquired pneumonia using electronic records, these issues led to poor classification. Limiting queries to accurate, complete records led to vastly reduced, possibly biased samples. We exploited knowledge latent in the electronic records to improve classification. A similarity metric was used to cluster cases. We defined discordance as the degree to which cases within a cluster give different answers for some query that addresses a classification task of interest. Cases with higher discordance are more likely to be incorrectly classified, and can be reviewed manually to adjust the classification, improve the query, or estimate the likely accuracy of the query. In a study of pneumonia--in which the ICD9-CM coding was found to be very poor--the discordance measure was statistically significantly correlated with classification correctness (.45; 95% CI .15-.62).

Adult↗

PubMed2006

Implementing a multidisease chronic care model in primary care using people and technology.

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.

Adult↗

PubMed2006

Use of health-related, quality-of-life metrics to predict mortality and hospitalizations in community-dwelling seniors.

OBJECTIVES: To investigate whether health-related quality-of-life (HRQoL) scores in a primary care population can be used as a predictor of future hospital utilization and mortality. DESIGN: Prospective cohort study measuring Short Form 12 (SF-12) scores obtained using a mailed survey. SF-12 scores, age, and a comorbidity score were used to predict hospitalization and mortality rate using multivariable logistic regression and Cox proportional hazards during the ensuing 28-month period for elderly patients. SETTING: Intermountain Health Care, a large integrated-delivery network serving a population of more than 150,000 seniors. PARTICIPANTS: Participants were senior patients who had one or more chronic diseases, were community dwelling, and were initially treated in primary care clinics. MEASUREMENTS: SF-12 survey Version 1. RESULTS: Seven thousand seventy-six surveys were sent to eligible participants; 3,042 (43%) were returned. Of the returned surveys, 2,166 (71%) were complete and scoreable. For the respondent group, a multivariable analysis demonstrated that older age, male sex, higher comorbidity score, and lower mental and physical summary measures of SF-12 predicted higher mortality and hospitalization. On average, nonresponders were older and had higher comorbidity scores and mortality rates than responders. CONCLUSION: The SF-12 survey provided additional predictive ability for future hospitalizations and mortality. Such predictive ability might facilitate preemptive interventions that would change the course of disease in this segment of the population. However, nonresponder bias may limit the utility of mailed SF-12 surveys in certain populations.

Aged↗

PubMed2005

Impact of generalist care managers on patients with diabetes.

OBJECTIVE: To determine how the addition of generalist care managers and collaborative information technology to an ambulatory team affects the care of patients with diabetes. STUDY SETTING: Multiple ambulatory clinics within Intermountain Health Care (IHC), a large integrated delivery network. STUDY DESIGN: A retrospective cohort study comparing diabetic patients treated by generalist care managers with matched controls was completed. Exposure patients had one or more contacts with a care manager; controls were matched on utilization, demographics, testing, and baseline glucose control. Using role-specific information technology to support their efforts, care managers assessed patients' readiness for change, followed guidelines, and educated and motivated patients. DATA COLLECTION: Patient data collected as part of an electronic patient record were combined with care manager-created databases to assess timely testing of glycosylated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels and changes in LDL and HbA1c levels. PRINCIPAL FINDINGS: In a multivariable model, the odds of being overdue for testing for HbA1c decreased by 21 percent in the exposure group (n=1,185) versus the control group (n=4,740). The odds of being tested when overdue for HbA1c or LDL increased by 49 and 26 percent, respectively, and the odds of HbA1c <7.0 percent also increased by 19 percent in the exposure group. The average HbA1c levels decreased more in the exposure group than in the controls. The effect on LDL was not significant. CONCLUSIONS: Generalist care managers using computer-supported diabetes management helped increase adherence to guidelines for testing and control of HbA1c levels, leading to improved health status of patients with diabetes.

Adolescent↗

PubMed2005

Drug-age alerting for outpatient geriatric prescriptions: a joint study using interoperable drug standards.

For more than a decade, the Beers criteria have identified specific medications that should generally be avoided in the geriatric population. Studies that have shown high prevalence rates of these potentially inappropriate medications have used disparate methodologies to identify these medications and hence are difficult to replicate and generalize. In an effort to improve prescribing behavior, we are building a drug-age alerting system utilizing standard drug coding systems for use in our Electronic Health Record (EHR) systems.

Aged↗

PubMed2002

The effect of sample size and disease prevalence on supervised machine learning of narrative data.

This paper examines the independent effects of outcome prevalence and training sample sizes on inductive learning performance. We trained 3 inductive learning algorithms (MC4, IB, and Naïve-Bayes) on 60 simulated datasets of parsed radiology text reports labeled with 6 disease states. Data sets were constructed to define positive outcome states at 4 prevalence rates (1, 5, 10, 25, and 50%) in training set sizes of 200 and 2,000 cases. We found that the effect of outcome prevalence is significant when outcome classes drop below 10% of cases. The effect appeared independent of sample size, induction algorithm used, or class label. Work is needed to identify methods of improving classifier performance when output classes are rare.

Algorithms↗

PubMedDate not supplied

Reference standards, judges, and comparison subjects: roles for experts in evaluating system performance.

Medical informatics systems are often designed to perform at the level of human experts. Evaluation of the performance of these systems is often constrained by lack of reference standards, either because the appropriate response is not known or because no simple appropriate response exists. Even when performance can be assessed, it is not always clear whether the performance is sufficient or reasonable. These challenges can be addressed if an evaluator enlists the help of clinical domain experts. 1) The experts can carry out the same tasks as the system, and then their responses can be combined to generate a reference standard. 2)The experts can judge the appropriateness of system output directly. 3) The experts can serve as comparison subjects with which the system can be compared. These are separate roles that have different implications for study design, metrics, and issues of reliability and validity. Diagrams help delineate the roles of experts in complex study designs.

Evaluation Studies as Topic↗