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At least 415 records · Page 23Linked to original sources
PubMed2005

Most Medicare outpatient visits are to physicians with limited clinical information technology.

This Data Bulletin uses linked data from two sources: the Centers for Medicare and Medicaid Services (CMS) 2001 5 Percent Carrier File, which contains complete claims for a representative sample of 5 percent of Medicare fee-for-service beneficiaries, and the 2001 Center for Studying Health System Change (HSC) Community Tracking Study (CTS) Physician Survey, a nationally representative survey of nearly 12,400 physicians. The linked sample includes claims for more than 506,000 Medicare outpatient visits to 8,641 CTS physicians. Estimates are weighted to be nationally representative of all Medicare fee-for-service physician outpatient visits in 2001. Use of the Medicare data is permitted under a data use agreement between Peter B. Bach, M.D., of Memorial Sloan-Kettering Cancer Center and CMS.

Age Factors↗
PubMed2005

Human and system errors, using adaptive turnaround documents to capture data in a busy practice.

Capturing coded clinical data for clinical decision support can improve care, but cost and disruption of clinic workflow present barriers to implementation. Previous work has shown that tailored, scannable paper forms (adaptive turnaround documents, ATDs) can achieve the benefits of computer-based clinical decision support at low cost and minimal disruption of workflow. ATDs are highly accurate under controlled circumstances, but accuracy in the setting of busy clinics with untrained physician users is untested. We recently developed and implemented such a system and studied rates of errors attributable to physician users and errors in the system. Prompts were used in 63% of encounters. Errors resulting from incorrectly marking forms occurred in 1.8% of prompts. System errors occurred in 7.2% of prompts. Most system errors were failures to capture data and may represent human errors in the scanning process. ATDs are an effective way to collect coded data from physicians. Further automation of the scanning process may reduce system errors.

Ambulatory Care Information Systems↗
PubMed1995

The impact of a guideline-driven computer charting system on the emergency care of patients with acute low back pain.

Federal guidelines for the treatment of acute low back pain were locally modified and made more specific. These guidelines were then programmed into a rule-based computer charting system which provides real-time advice regarding documentation, testing, treatment, and disposition of emergency department patients with this condition. In a time-series off-on experiment the system was shown to significantly improve documentation of the medical record and discharge instructions. There was little effect on the appropriateness of testing and treatment and the cost of care. These findings contrast with our previous experiment using a similar program for the care of health care workers exposed to body fluids. In that study both the appropriateness of care and the cost-effectiveness of care were substantially improved.

Acute Disease↗
PubMed2006

Interventions to improve adherence to medication in people with type 2 diabetes mellitus: a review of the literature on the role of pharmacists.

BACKGROUND AND OBJECTIVE: Pharmacists are now adopting a crucial role in the management of chronic illness in primary care, providing diabetes care and advice. This review aims to show whether a range of diabetes care interventions delivered by pharmacists is successful in improving adherence to medication. METHODS: The studies reviewed formed a subgroup of a Cochrane review on interventions to improve adherence to medication in people with type 2 diabetes. Search terms were 'type 2 diabetes mellitus' and 'compliance' or 'adherence'. Studies were included if they assessed adherence to medical treatment specifically, rather than other aspects of self-management. Out of the 21 studies selected for review, five described an intervention delivered by a pharmacist. RESULTS AND DISCUSSION: Two studies reported on attempts to improve adherence focused on the taking of medication. A system of reminders and packaging improved medication adherence, but measuring medicine taking through pill counts or Medication Event Monitoring System was not effective. Three studies evaluated pharmacist-led integrated management and education programmes designed to improve glycaemic control for under-served patient populations. They all succeeded in lowering glycated haemoglobin, but it remains unclear whether this resulted from improved patient adherence. CONCLUSION: This review indicates a potential benefit of pharmacist interventions to improve medication adherence in diabetes, especially in providing patient education.

Diabetes Mellitus, Type 2↗
PubMed2001

Automated attention flags in chronic disease care planning.

OBJECTIVES: To assess the value of computerised decision support in the management of chronic respiratory disease by comparing agreement between three respiratory specialists, general practitioners (care coordinators), and decision support software. METHODS: Care guidelines for two chronic obstructive pulmonary disease projects of the SA HealthPlus Coordinated Care Trial were formulated. Decision support software, Care Plan On-Line (CPOL), was created to represent the intent of these guidelines via automated attention flags to appear in patients' electronic medical records. For a random sample of 20 patients with care plans, decisions about the use of nine additional services (eg, smoking cessation, pneumococcal vaccination) were compared between the respiratory specialists, the patients' GPs and the CPOL attention flags. RESULTS: Agreement among the specialists was at the lower end of moderate (intraclass correlation coefficient [ICC], 0.48; 95% CI, 0.39-0.56), with a 20% rate of contradictory decisions. Agreement with recommendations of specialists was moderate to poor for GPs (kappa, 0.49; 95% CI, 0.33-0.66) and moderate to good for CPOL (kappa, 0.72; 95% CI, 0.55-0.90). CPOL agreement with GPs was moderate to poor (kappa, 0.41; 95% CI, 0.24-0.58). GPs were less likely than specialists or CPOL to decide in favour of an additional service (P<0.001). CPOL was 87% accurate as an indicator of specialist decisions. It gave a 16% false-positive rate according to specialist decisions, and flagged 61% of decisions where GPs said No and specialists said Yes. CONCLUSIONS: Automated decision support may provide GPs with improved access to the intent of guidelines; however, further investigation is required.

Decision Support Systems, Clinical↗
PubMed2000

Implementing clinical practice guidelines while taking account of changing evidence: ATHENA DSS, an easily modifiable decision-support system for managing hypertension in primary care.

This paper describes the ATHENA Decision Support System (DSS), which operationalizes guidelines for hypertension using the EON architecture. ATHENA DSS encourages blood pressure control and recommends guideline-concordant choice of drug therapy in relation to comorbid diseases. ATHENA DSS has an easily modifiable knowledge base that specifies eligibility criteria, risk stratification, blood pressure targets, relevant comorbid diseases, guideline-recommended drug classes for patients with comorbid disease, preferred drugs within each drug class, and clinical messages. Because evidence for best management of hypertension evolves continually, ATHENA DSS is designed to allow clinical experts to customize the knowledge base to incorporate new evidence or to reflect local interpretations of guideline ambiguities. Together with its database mediator Athenaeum, ATHENA DSS has physical and logical data independence from the legacy Computerized Patient Record System (CPRS) supplying the patient data, so it can be integrated into a variety of electronic medical record systems.

Artificial Intelligence↗
PubMed1994

Prompting physicians for cost-effective test ordering in the low prevalence conditions of family medicine.

We have developed a computerized prompting system for test ordering which we feel will decrease the cost of investigations and at the same time promote an evidence based learning approach to test ordering. Prompting systems have been shown to be cost-effective but suffer from many disadvantages in the family practice setting. They tend to be difficult to modify by the user and contingent on an inflexible rule based structure. Many suggestions are ignored implying that they are not relevant. In family practice most conditions are of low prevalence. Prompting for test ordering where the pre-test likelihood of disease is small will result in a large number of false positives and many unnecessary repeat or confirmatory investigations and attendant anxiety unless the prompting system is specifically designed to be used in a low prevalence environment. PROMPTOR-FM (PRObabilistic Method of Prompting for Test ORdering in Family Medicine) was developed to overcome these perceived difficulties. It allows the physician to rapidly calculate the positive and negative predictive values of a test being considered based on the clinical index of suspicion. The physician is able to repeat the calculations and compare the results with previous calculations. By using PROMPTOR-FM repetitively, the clinician can learn to balance the risk of "missing" a rare but serious condition against the risk of falsely identifying disease with its downstream hazards and costs of further investigation. Prompting for test ordering is therefore uniquely tailored to each patient's situation.

Artificial Intelligence↗
PubMed2005

Electronic alerts to prevent venous thromboembolism among hospitalized patients.

BACKGROUND: Prophylaxis against deep-vein thrombosis in hospitalized patients remains underused. We hypothesized that the use of a computer-alert program to encourage prophylaxis might reduce the frequency of deep-vein thrombosis among high-risk hospitalized patients. METHODS: We developed a computer program linked to the patient database to identify consecutive hospitalized patients at risk for deep-vein thrombosis in the absence of prophylaxis. The program used medical-record numbers to randomly assign 1255 eligible patients to an intervention group, in which the responsible physician was alerted to a patient's risk of deep-vein thrombosis, and 1251 patients to a control group, in which no alert was issued. The physician was required to acknowledge the alert and could then withhold or order prophylaxis, including graduated compression stockings, pneumatic compression boots, unfractionated heparin, low-molecular-weight heparin, or warfarin. The primary end point was clinically diagnosed, objectively confirmed deep-vein thrombosis or pulmonary embolism at 90 days. RESULTS: More patients in the intervention group than in the control group received mechanical prophylaxis (10.0 percent vs. 1.5 percent, P<0.001) or pharmacologic prophylaxis (23.6 percent vs. 13.0 percent, P<0.001). The primary end point occurred in 61 patients (4.9 percent) in the intervention group, as compared with 103 (8.2 percent) in the control group; the Kaplan-Meier estimates of the likelihood of freedom from deep-vein thrombosis or pulmonary embolism at 90 days were 94.1 percent (95 percent confidence interval, 92.5 to 95.4 percent) and 90.6 percent (95 percent confidence interval, 88.7 to 92.2 percent), respectively (P<0.001). The computer alert reduced the risk of deep-vein thrombosis or pulmonary embolism at 90 days by 41 percent (hazard ratio, 0.59; 95 percent confidence interval, 0.43 to 0.81; P=0.001). CONCLUSIONS: The institution of a computer-alert program increased physicians' use of prophylaxis and markedly reduced the rates of deep-vein thrombosis and pulmonary embolism among hospitalized patients at risk.

Adolescent↗
PubMed2005

Improving acceptance of computerized prescribing alerts in ambulatory care.

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians.

Adult↗
PubMed1994

A "high-tech," "soft-touch" immunization program for members of a Medicaid managed care organization.

Immunization rates among the very poor are critically low. The solution to improving rates requires technological tracking of immunizations linked to extensive home visiting outreach services as well as physician and member support services to increase compliance with recommended immunization schedules. This paper describes the development and implementation of a comprehensive immunization program which incorporates these strategies for members of a Medicaid managed care organization. Analysis of preliminary data provides some indication of the value of the tracking system and the effectiveness of incentives and home visiting on member compliance with immunizations.

Accounting↗
PubMedDate not supplied

Computerized patient records: current and future opportunities.

Although computerized patient record (CPR) technology holds tangible promise for improvements in the quality of patient care, its penetration into physician practices has been slow at best. This article describes the operational and quality of care benefits of CPR implementation and the barriers to implementation. These include technology limitations, cultural factors, lack of standards, downtime fears, security and privacy concerns, and the lack of alignment of economic incentives. The article also provides non-radical approaches (i.e., simpler and cheaper) ways to harness technology to improve office efficiencies and patient care.

Attitude to Computers↗