Using commercial knowledge bases for clinical decision support: opportunities, hurdles, and recommendations.
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Commerce↗
Biomedical subjects
Richard M Reichley
Publications and source records attributed to Richard M Reichley.
Implementing a commercial rule base as a medication order safety net.
A commercial rule base (Cerner Multum) was used to identify medication orders exceeding recommended dosage limits at five hospitals within BJC HealthCare, an integrated health care system. During initial testing, clinical pharmacists determined that there was an excessive number of nuisance and clinically insignificant alerts, with an overall alert rate of 9.2%. A method for customizing the commercial rule base was implemented to increase rule specificity for problematic rules. The system was subsequently deployed at two facilities and achieved alert rates of less than 1%. Pharmacists screened these alerts and contacted ordering physicians in 21% of cases. Physicians made therapeutic changes in response to 38% of alerts presented to them. By applying simple techniques to customize rules, commercial rule bases can be used to rapidly deploy a safety net to screen drug orders for excessive dosages, while preserving the rule architecture for later implementations of more finely tuned clinical decision support.
Clinical Pharmacy Information Systems↗
Pseudomonas aeruginosa bloodstream infection: importance of appropriate initial antimicrobial treatment.
Pseudomonas aeruginosa bloodstream infection is a serious infection with significant patient mortality and health-care costs. Nevertheless, the relationship between initial appropriate antimicrobial treatment and clinical outcomes is not well established. This study was a retrospective cohort analysis employing automated patient medical records and the pharmacy database at Barnes-Jewish Hospital. Three hundred five patients with P. aeruginosa bloodstream infection were identified over a 6-year period (January 1997 through December 2002). Sixty-four (21.0%) patients died during hospitalization. Hospital mortality was statistically greater for patients receiving inappropriate initial antimicrobial treatment (n = 75) compared to appropriate initial treatment (n = 230) (30.7% versus 17.8%; P = 0.018). Multiple logistic regression analysis identified inappropriate initial antimicrobial treatment (adjusted odds ratio [AOR], 2.04; 95% confidence interval [CI], 1.42 to 2.92; P = 0.048), respiratory failure (AOR, 5.18; 95% CI, 3.30 to 8.13; P < 0.001), and circulatory shock (AOR, 4.00; 95% CI, 2.71 to 5.91; P < 0.001) as independent determinants of hospital mortality. Appropriate initial antimicrobial treatment was administered statistically more often among patients receiving empirical combination antimicrobial treatment for gram-negative bacteria compared to empirical monotherapy (79.4% versus 65.5%; P = 0.011). Inappropriate initial empirical antimicrobial treatment is associated with greater hospital mortality among patients with P. aeruginosa bloodstream infection. Inappropriate antimicrobial treatment of P. aeruginosa bloodstream infections may be minimized by increased use of combination antimicrobial treatment until susceptibility results become known.
Adult↗
Strategies for reducing nuisance alerts in a dose checking application.
Commercial rule bases can be implemented to identify medication orders that fall outside recommended dosage ranges, but they are likely to produce an excessive number of nuisance and clinically insignificant alerts. Strategies for customizing commercial dosing rules can be implemented to minimize this problem. This paper describes specific strategies implemented in a dose checking application necessary for achieving a clinically acceptable alert rate.
Clinical Pharmacy Information Systems↗
Automatic detection of spironolactone - related adverse drug events.
Due to increasing reports of spironolactone associated life-threatening hyperkalemia, we implemented a rule in our automated event detection system to monitor serum potassium results in patients receiving spironolactone. In 2004, 419 (10.49%) of 3995 admissions at 3 BJC HealthCare hospitals were identified as having hyperkalemia while on spironolactone. For a 9-month period in one facility, 33 of 52 automatically detected potential ADEs had been validated by pharmacists through manual chart review to have spironolactone as a contributing factor (PPV=63.5%).
Adverse Drug Reaction Reporting Systems↗
Construction and validation of an automated model for the early identification of patients hospitalized for heart failure.
In order to institute early hospital-wide interventions, we constructed a reliable automated model for identifying newly admitted patients with congestive heart failure using electronically captured administrative and clinical data.
Adult↗
Physicians' knowledge and attitudes about coronary heart disease prevention guidelines and technology assisted interventions.
BJC Healthcare is conducting a randomized controlled study to evaluate the impact of a technology-assisted pharmacist intervention on physicians' adherence to national coronary heart disease (CHD) prevention guidelines. We surveyed physicians to assess their knowledge of the guidelines and attitudes toward pharmacist-mediated interventions.
Attitude of Health Personnel↗
Customizing a commercial rule base for detecting drug-drug interactions.
We developed and implemented an adverse drug event system (PharmADE) that detects potentially dangerous drug combinations using a commercial rule base. While commercial rule bases can be useful for rapid deployment of a safety net to screen for drug-drug interactions, they sometimes do not provide the desired rule sensitivity. We implemented methods for enhancing commercial drug-drug interaction rules while preserving the original rule base architecture for easy and low cost maintenance.
Adverse Drug Reaction Reporting Systems↗
Concordance between medication histories and outpatient electronic prescription claims in patients hospitalized with heart failure.
Using an electronic prescription claims database and electronic hospital records, we retrospectively compared outpatient heart failure (HF) prescriptions dispensed with reported use obtained during medication histories taken at hospital admission. We found significant disagreement between each source for all but one HF medication class.
Clinical Pharmacy Information Systems↗
Monitoring pharmacy expert system performance using statistical process control methodology.
Automated expert systems provide a reliable and effective way to improve patient safety in a hospital environment. Their ability to analyze large amounts of data without fatigue is a decided advantage over clinicians who perform the same tasks. As dependence on expert systems increase and the systems become more complex, it is important to closely monitor their performance. Failure to generate alerts can jeopardize the health and safety of patients, while generating excessive false positive alerts can lead to valid alerts being dismissed as noise. In this study, statistical process control charts were used to monitor an expert system, and the strengths and weaknesses of this technology are presented.
Clinical Pharmacy Information Systems↗
Implementing a commercial rule base as a medication order safety net.
A commercial rule base was used to identify drug orders exceeding standard dosage limits at a university hospital. Initially, there were substantial numbers of clinically insignificant alerts. A method for altering the commercial rule base will be implemented to increase rule specificity for problematic drugs. With minor modifications, commercial rule bases can be used to rapidly create a safety net that screens drug orders for excessive dosages, while preserving the rule architecture for more finely tuned clinical decision support.
Drug Therapy, Computer-Assisted↗