Delivering informed care.
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Academic Medical Centers↗
Biomedical subjects
Saverio M Maviglia
Publications and source records attributed to Saverio M Maviglia.
KnowledgeLink: impact of context-sensitive information retrieval on clinicians' information needs.
OBJECTIVE: Infobuttons are message-based content search and retrieval functions embedded within other applications that dynamically return information relevant to the clinical task at hand. The objective of this study was to determine whether infobuttons effectively answer providers' questions about medications or affect patient care decisions. DESIGN: The authors implemented and evaluated a medication infobutton application called KnowledgeLink. Health care providers at 18 outpatient clinics were randomized to one of two versions of KnowledgeLink, one that linked to information from Micromedex (Thomson Micromedex, Greenwood Village, Co) and the other to material from SkolarMD (Wolters Kluwer Health, Palo Alto, CA). MEASUREMENTS: Data were collected about the frequency of use and demographics of users, patients, and drugs that were queried. Users were periodically surveyed with short questionnaires and then with a more extensive survey at the end of one year. RESULTS: During the first year, KnowledgeLink was used 7,972 times by 359 users to look up information about 1,723 medications for 4,961 patients. Clinicians used KnowledgeLink twice a month on average, and during an average of 1.2% of patient encounters. KnowledgeLink was used by a wide variety of medical staff, not just physicians and nurse practitioners. The frequency of usage and the questions asked varied with user role (primary care physician, specialist physician, nurse practitioner). Although the median KnowledgeLink session was brief (21 seconds), KnowledgeLink answered users' queries 84% of the time, and altered patient care decisions 15% of the time. Users rated KnowledgeLink favorably on multiple scales, recommended extending KnowledgeLink to other content domains, and suggested enhancing the interface to allow refinement of the query and selection of the target resource. CONCLUSION: An infobutton can satisfy information needs about medications. Although used infrequently and for brief sessions, KnowledgeLink was positively received, answered most users' questions, and had a significant impact on medical decision making. The next steps would be to broaden the domains that KnowledgeLink covers to more specifically tailor results to the user type, to provide options when queries are not immediately answered, and to implement KnowledgeLink within other electronic clinical applications.
Analysis of Variance↗
Patient safety concerns arising from test results that return after hospital discharge.
BACKGROUND: Failure to relay information about test results pending when patients are discharged from the hospital may pose an important patient-safety problem. Few data are available on the epidemiology of test results pending at discharge or on physician awareness of these results. OBJECTIVE: To determine the prevalence, characteristics, and physician awareness of potentially actionable laboratory and radiologic test results returning after hospital discharge. DESIGN: Cross-sectional study. SETTING: Two tertiary care academic hospitals. PATIENTS: 2644 consecutive patients discharged from hospitalist services from February to June 2004. MEASUREMENTS: The main outcomes were the prevalence and characteristics of potentially actionable test results returning after hospital discharge, awareness of these results by inpatient and primary care physicians, and satisfaction of inpatient physicians with current systems for follow-up on test results. The authors prospectively collected data on test results pending at the time of discharge and, as results returned after discharge, surveyed hospitalists, junior residents, and primary care physicians about those results that were potentially actionable according to a physician-reviewer. RESULTS: A total of 1095 patients (41%) had 2033 test results return after discharge. Of these results, 191 (9.4% [95% CI, 8.0% to 11.0%]) were potentially actionable. Surveys were sent regarding 155 results, and 105 responses were returned. Of the 105 results in the surveys with responses, physicians had been unaware of 65 (61.6% [CI, 51.3% to 70.9%]); of these 65, they agreed with physician-reviewers that 24 (37.1% [CI, 25.7% to 50.2%]) were actionable and 8 (12.6% [CI, 6.4% to 23.3%]) required urgent action. Inpatient physicians were dissatisfied with their systems for following up on test results returning after discharge. LIMITATIONS: The authors were unable to determine whether physicians' lack of awareness of test results returning after discharge was associated with adverse outcomes. CONCLUSIONS: Many patients are discharged from hospitals with test results still pending, and physicians are often unaware of potentially actionable test results returning after discharge. Further work is needed to design better follow-up systems for test results returning after hospital discharge.
Clinical Laboratory Techniques↗
Ambulatory hypercholesterolemia management in patients with atherosclerosis. Gender and race differences in processes and outcomes.
OBJECTIVE: To determine whether outpatient cholesterol management varies by gender or race among patients with atherosclerosis, and assess factors related to subsequent cholesterol control. DESIGN: Retrospective cohort study. SETTING: Primary care clinics affiliated with an academic medical center. PARTICIPANTS: Two hundred forty-three patients with coronary heart disease, cerebrovascular disease, or peripheral vascular disease and low-density lipoprotein cholesterol (LDL-C)>130 mg/dl. MEASUREMENTS AND MAIN RESULTS: The primary process of care assessed for 1,082 office visits was cholesterol management (medication intensification or LDL-C monitoring). Cholesterol management occurred at 31.2% of women's and 38.5% of men's visits (P=.01), and 37.3% of black and 31.7% of white patients' visits (P=.09). Independent predictors of cholesterol management included female gender (adjusted risk ratio [ARR], 0.77; 95% confidence interval [CI], 0.60 to 0.97), seeing a primary care clinician other than the patient's primary care physician (ARR, 0.23; 95% CI, 0.11 to 0.45), and having a new clinical problem addressed (ARR, 0.60; 95% CI, 0.48 to 0.74). After 1 year, LDL-C <130 mg/dl occurred less often for women than men (41% vs 61%; P=.003), black than white patients (39% vs 58%; P=.01), and patients with only Medicare insurance than with commercial insurance (37% vs 58%; P=.008). Adjustment for clinical characteristics and management attenuated the relationship between achieving an LDL-C <130 mg/dl and gender. CONCLUSIONS: In this high-risk population with uncontrolled cholesterol, cholesterol management was less intensive for women than men but similar for black and white patients. Less intense cholesterol management accounted for some of the disparity in cholesterol control between women and men but not between black and white patients.
Academic Medical Centers↗
Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool.
BACKGROUND: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at the time of data entry can be challenging. OBJECTIVE: To develop a problem list dictionary and search algorithm for an EMR system and evaluate its use. METHODS: We developed a problem list dictionary and lookup tool and implemented it in several EMR systems. A sample of 10,000 problem entries was reviewed from each system to assess overall coding rates. We also performed a manual review of a subset of entries to determine the appropriateness of coded entries, and to assess the reasons other entries were left uncoded. RESULTS: The overall coding rate varied significantly between different EMR implementations (63-79%). Coded entries were virtually always appropriate (99%). The most frequent reasons for uncoded entries were due to user interface failures (44-45%), insufficient dictionary coverage (20-32%), and non-problem entries (10-12%). CONCLUSION: The problem list dictionary and search algorithm has achieved a good coding rate, but the rate is dependent on the specific user interface implementation. Problem coding is essential for providing clinical decision support, and improving usability should result in better coding rates.
Algorithms↗
KnowledgeLink update: just-in-time context-sensitive information retrieval.
Medical knowledge expands at a pace that makes it impossible for the individual clinician to keep up, especially for medications. Medication-related queries are the most common type of query that typically go unanswered during the course of providing care.1 Unanswered questions may result in errors, as found in one study evaluating systems failures associated with adverse drug events. This study found that better information might have prevented half of serious medication errors, and that lack of drug-specific knowledge accounted for the single largest proportion of these events (29%).2 While this information was available somewhere (either on paper or electronically), it was not at the providers' fingertips. Information technology should anticipate clinicians' needs, and bring the information they require to the point of care. For this purpose, we developed an application extender called KnowledgeLink, which provides "just-in-time" context-sensitive information retrieval for drug-related queries.
Drug Therapy, Computer-Assisted↗
Automating complex guidelines for chronic disease: lessons learned.
There is scant published experience with implementing complex, multistep computerized practice guidelines for the long-term management of chronic diseases. We have implemented a system for creating, maintaining, and navigating computer-based clinical algorithms integrated with our electronic medical record. This article describes our progress and reports on lessons learned that might guide future work in this field. We discuss issues and obstacles related to choosing and adapting a guideline for electronic implementation, representing and executing the guideline as a computerized algorithm, and integrating it into the clinical workflow of outpatient care. Although obstacles were encountered at each of these steps, the most difficult were related to workflow integration.
Algorithms↗