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PubMed2000

Enhancing the expressiveness of structured reporting systems.

The overall goal of this research is to build a structured reporting system that reduces the cost, delays, and inconvenience associated with conventional dictation and speech recognition systems. We have implemented such a structured reporting system for radiology that replaces current dictation and transcription processes by allowing radiologists and other imaging professionals to select imaging findings from a medical lexicon. The system uses an imaging-specific information model, called a "description set,' to organize selected terms in a relational database. Unique features of the knowledge representation that enhance its expressiveness include its ability to codify uncertainty about an imaging observation and to represent explicitly the logical relationships among imaging findings. In addition, the system does not require the user to fill in "blanks' in a static text template. Instead, it allows entry of terms in arbitrary order and uses automated text-generation techniques to create a text report that referring physicians are accustomed to receiving. In parallel, the system also produces a multimedia report that the referring physician can use as a quick reference. Unlike the results of conventional dictation or speech recognition, each finding is coded in a relational database for later information processing. Thus, the structured report database can be used to index images by content, to provide real-time decision support, to enhance radiologists' performance, to conduct exploratory clinical research, and to transmit imaging report data to computer-based patient record systems.

Abstracting and Indexing↗
PubMed1998

Decision support for medication use in an inpatient physician order entry application and a pharmacy application.

Studies have shown that adverse drug events are common, expensive, and due to causes that can be remedied by information technologies. At our institution we have developed a physician order entry application and a pharmacy application designed to decrease the risk of such adverse drug events. In this paper, we describe the applications, with attention to the clinical decision support features present in each. We also describe the manner in which the two applications interact.

Clinical Pharmacy Information Systems↗
PubMedDate not supplied

CPOE primer.

If you don't already have it, get ready for it. Computerized physician order entry (CPOE) is most likely coming your way. Discover some of the ifs, ands and buts of identifying and implementing a CPOE systems.

Diffusion of Innovation↗
PubMed2002

Security of medical multimedia.

The application of information technology to health care has generated growing concern about the privacy and security of medical information. Furthermore, data and communication security requirements in the field of multimedia are higher. In this paper we describe firstly the most important security requirements that must be fulfilled by multimedia medical data, and the security measures used to satisfy these requirements. These security measures are based mainly on modern cryptographic and watermarking mechanisms as well as on security infrastructures. The objective of our work is to complete this picture, exploiting the capabilities of multimedia medical data to define and implement an authorization model for regulating access to the data. In this paper we describe an extended role-based access control model by considering, within the specification of the role-permission relationship phase, the constraints that must be satisfied in order for the holders of the permission to use those permissions. The use of constraints allows role-based access control to be tailored to specifiy very fine-grained and flexible content-, context- and time-based access control policies. Other restrictions, such as role entry restriction also can be captured. Finally, the description of system architecture for a secure DBMS is presented.

Computer Security↗
PubMedDate not supplied

Does national regulatory mandate of provider order entry portend greater benefit than risk for health care delivery? The 2001 ACMI debate. The American College of Medical Informatics.

The 2001 debate of the American College of Medical Informatics focused on the proposition that national regulatory mandate of computer-based provider order entry (CPOE), to take effect by the end of 2005, portends greater benefit than risk for health care delivery. Both sides accepted that provider order entry offers potential benefit. Those supporting the proposition emphasized public safety, noting that payers have little economic incentive to pay for quality and that a mandate would force vendors to improve the usability and value of their systems. They argued that the mandate would align the economic incentives to finally allow CPOE to be widely adopted. Those opposing the proposition emphasized the risks resulting from a mandate, including the direct implementation costs, the logistic issues of implementation, and the cost of failed implementations. They also noted the potential for errors introduced by the systems themselves and the fact that the safety and utility of commercially available CPOE products have yet to be proved.

Delivery of Health Care↗
PubMed1985

[Radiation protection in mammography].

According to the generally held view, objections in terms of radiation hygiene are less important in individually indicated mammographic investigations. Radiation protection in mammography is restricted to the carcinogenic side effect of radiation exposure in mass screening of asymptomatic women. A dose-proportional carcinogenic side effect independent of the dose distribution in time is also to be assumed in the small dose range. The International Radiation Protection Commission therefore requires a cost-benefit analysis to including costs for all mass X-ray examinations. It is indispensable to consider each age group separately in order to arrive at a rational and medically acceptable result. Cost/benefit analyses integrated over all age groups obscure important decision indicators with their positive results throughout. In a differentiated consideration, one arrives at a minimum age of entry for participation of asymptomatic women in regular mass screening. This depends on the dose requirement of the system used. The available recommendations tend to be restrictive in the case of relatively high dose requirement, and can be interpreted more extensively in the case of lower dose requirement. Inclusion of younger age groups with very low incidence which is possible in terms of risk criteria after a major lowering of the dose requirement leads to a low specific benefit and high specific costs, i.e. to a poor cost/benefit relation. Objections to the cost/benefit analyses undertaken could be shown to be based on the neglect of an age-differentiated consideration, one-sided selection of material, selective interpretation of the literature, inadmissible generalizations, the highlighting of relatively implausible assumptions, fundamental errors and argumentations colored by professional interest.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed2002

Multidisciplinary approaches to reducing error and risk in a patient care setting.

In 1995, a medication error at Boston's Dana-Farber Cancer Institute (DFCI) that received intense media scrutiny, transformed the Institute in many ways. Primarily, patient safety became a major priority that led to Institute-wide organizational learning. As a result, DFCI emerged as a national leader in the patient safety movement. A key factor believed to have contributed to this effort was the use of a multidisciplinary team approach to identifying and preventing errors, with the patient and family members as an integral part of the team. In addition to teamwork, other activities included implementing a new chemotherapy order entry system, transforming the culture to a non-punitive one where staff are encouraged to openly discuss errors and safety issues, and introducing a root cause analysis process for error/near miss investigations. Several guiding principles served as the foundation for the efforts including: 1) systems, not individuals, must be the focus of safety initiatives; 2) organizations must create a non-punitive culture; 3) changes must be hard-wired into systems; and 4) multidisciplinary participation, including patients and families, is critical to success.

Boston↗
PubMed2002

CPOE (computerized physician order entry). An executive's guide.

Computerized physician order entry is controversial. Backers say it helps reduce medication errors significantly. Critics note that it's expensive, as well as complex to design and implement. This guide considers the advantages and costs of CPOE.

Attitude to Computers↗
PubMed2003

A chemotherapy incident reporting and improvement system.

BACKGROUND: The Vanderbilt University Medical Center (VUMC) has designed and deployed the Chemotherapy Incident Reporting and Improvement System (CIRIS), which is embedded into daily care processes. The system uses commercial information technologies, including handheld computers, to create a mobile Web-based chemotherapy incident reporting system for nurses and pharmacists. Two phases--(1) development and implementation of the CIRIS incident reporting safety registry and (2) development of the handheld-computer interface--were implemented. The final phase entails integration of the computerized order entry system into the front end of the CIRIS architecture. The voluntary incident reporting system data are stored over time for use by the multidisciplinary safety improvement team. RESULTS: Staff buy-in has been demonstrated by increased reporting rates, the high number of provider-initiated improvements made to the reporting tool during the first year of implementation, and specific chemotherapy safety interventions conceived from analysis of the reported data. CONCLUSION: The CIRIS model for pediatric chemotherapy safety improvement has been implemented in the inpatient setting but could easily be configured for a variety of other clinical applications in inpatient or outpatient settings. CIRIS has been effective, especially in the chemotherapy pharmacy, where incident reporting has increased dramatically.

Child↗
PubMed1992

A computerized intensive care unit order-writing protocol.

OBJECTIVE: To present a computerized intensive care unit order-writing protocol. DESIGN: Descriptive report. SETTING: Eight-bed surgical intensive care unit, Department of Surgery, Department of Veterans Affairs Medical Center, Bronx, NY. METHODS: IBM-based, computer network program that provides user-friendly, logical, and comprehensive organ-system order sequences for patient management. RESULTS: Since July 1988, an order program that stresses (1) improved and more efficient patient care, (2) the use of program-integrated automatic safety features, (3) the substitution of computer entry for handwriting, and (4) the assurance that physicians deliver obligatory care in a logical organ-system-based progression has been implemented. CONCLUSIONS: The order protocol system presented is simple to introduce and operate, has minimal training and technical requirements, and is demonstrably reliable.

Computer Security↗
PubMed2004

Computer physician order entry and the real world: we're only humans.

BACKGROUND: Computer physician order entry (CPOE) may have significant benefit to reducing medical errors in the hospital setting. The belief in the promise of CPOE has led organizations such as the Leap Frog Group to advocate for the implementation of CPOE in hospitals to improve patient safety. Human factors, or ergonomics, is the study of the interaction between humans and the systems and tools they use. It is unclear whether human factors principles have been applied to commercially available CPOE systems. CONCLUSIONS: CPOE's true utility for preventing medical errors and harm is largely undetermined. The evidence that exists for error reduction with CPOE is in the setting of "homegrown" systems and not commercially available products. The cases portrayed in the two scenarios described in this article were drawn from actual events to illustrate how failure to attend to human factors and human-centered design can create or facilitate errors and harm. RECOMMENDATIONS FOR ORGANIZATIONS IN IMPLEMENTING, CPOE: Organizations implementing CPOE or considering doing so could evaluate potential systems on the basis of evidence for human-centered design. An organization interested in addressing human factors issues as they relate to CPOE might, for example, familiarize itself with the basics of human factors, usability, and with existing evaluation methods for CPOE; involve the people who do the daily work in the evaluation and selection process; and ask potential vendors how they have addressed human factors in their CPOE systems.

Drug Prescriptions↗
PubMed1996

Recognizing noun phrases in medical discharge summaries: an evaluation of two natural language parsers.

We evaluated the ability of two natural language parsers, CLARIT and the Xerox Tagger, to identify simple, noun phrases in medical discharge summaries. In twenty randomly selected discharge summaries, there were 1909 unique simple noun phrases. CLARIT and the Xerox Tagger exactly identified 77.0% and 68.7% of the phrases, respectively, and partially identified 85.7% and 80.8% of the phrases. Neither system had been specially modified or tuned to the medical domain. These results suggest that it is possible to apply existing natural language processing (NLP) techniques to large bodies of medical text, in order to empirically identify the terminology used in medicine. Virtually all the noun phrases could be regarded as having special medical connotation and would be candidates for entry into a controlled medical vocabulary.

Medical Records↗
PubMed1994

Physician use of a computerized medical record system during the patient encounter: a descriptive study.

The computerized medical record program, CLINIC, specifically designed at Ben-Gurion University of the Negev to be used on-line in a primary care clinic during a patient encounter by healthcare professionals, has been in use for over 6 years in two community clinics. In order to analyse the effectiveness and use of CLINIC, four physicians were video recorded during working sessions before and after the introduction of CLINIC. While using CLINIC did not change the total mean encounter time, the lengths of the encounter components and record use did change. The physicians' work style changed from a 'conversational pattern' (continuous data recording) to a 'blocked pattern' (data entry at intervals).

Attitude of Health Personnel↗
PubMedDate not supplied

Organizational and cultural changes for providing safe patient care.

OBJECTIVE: To describe an approach and experience with fostering a culture of patient safety. METHODS: (1) Organizational Change-The Department of Medicine established a patient safety committee (PSC) and charged it with reviewing adverse events. (2) Cultural Change-PSC sponsors and participants work to promote a culture of collaboration, study, learning, and prevention versus a culture of blame. (3) Collaboration-The PSC includes chief residents and members from medical informatics, nursing, pharmacy, quality assurance, risk management, and utilization management. (4) Evolution-The duties of the PSC progressed from merely learning from adverse event reports to implementing patient safety and quality improvement projects. (5) Standardization-The PSC uses standard definitions and procedures when reviewing cases of adverse events, and when conducting patient safety and quality improvement projects. RESULTS: (1) Developed an online adverse event reporting system, shortening the average report collection time by 2 days and increasing the number of adverse events reported. (2) Established a model for change using (a) safety rounds with residents, (b) e-mail safety alerts, and, in some cases, (c) decision alerts using electronic order entry. These changes in culture and capability led to improvements in care and improved financial results. CONCLUSIONS: Senior management support of a culture of learning and prevention and an organizational structure that promotes collaboration has provided an environment in which patient safety initiatives can flourish by providing not only safer and higher quality patient care but also a positive financial return on investment.

Decision Support Systems, Clinical↗
PubMed1993

Response to a trial of physician-based inpatient order entry.

Our group has developed a physician-operated inpatient order-entry system (BICS-OE). Mindful of the problems inherent in bringing a radical cultural change such as this to the hospital, we conducted two pilots of the system prior to its full implementation. Physicians and nurses both identified a number of benefits from the use of OE. Physicians reported a number of areas where OE use was difficult or could be improved; nurses reported fewer problems. Based on the pilot trials, we modified the interface and some data constructs. These changes have enhanced the usefulness of OE in patient care in our hospital, and can serve as a model to others developing order entry.

Attitude to Computers↗
PubMedDate not supplied

Contrasting views of physicians and nurses about an inpatient computer-based provider order-entry system.

OBJECTIVE: Many hospitals are investing in computer-based provider order-entry (POE) systems, and providers' evaluations have proved important for the success of the systems. The authors assessed how physicians and nurses viewed the effects of one modified commercial POE system on time spent patients, resource utilization, errors with orders, and overall quality of care. DESIGN: Survey. MEASUREMENTS: Opinions of 271 POE users on medicine wards of an urban teaching hospital: 96 medical house officers, 49 attending physicians, 19 clinical fellows with heavy inpatient loads, and 107 nurses. RESULTS: Responses were received from 85 percent of the sample. Most physicians and nurses agreed that orders were executed faster under POE. About 30 percent of house officers and attendings or fellows, compared with 56 percent of nurses, reported improvement in overall quality of care with POE. Forty-four percent of house officers and 34 percent of attendings/fellows reported that their time with patients decreased, whereas 56 percent of nurses indicated that their time with patients increased (P < 0.001). Sixty percent of house officers and 41 percent of attendings/fellows indicated that order errors increased, whereas 69 percent of nurses indicated a decrease or no change in errors. Although most nurses reported no change in the frequency of ordering tests and medications with POE, 61 percent of house officers reported an increased frequency. CONCLUSION: Physicians and nurses had markedly different views about effects of a POE system on patient care, highlighting the need to consider both perspectives when assessing the impact of POE. With this POE system, most nurses saw beneficial effects, whereas many physicians saw negative effects.

Attitude to Computers↗
PubMed2000

Promoting patient safety and preventing medical error in emergency departments.

An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are, individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system-level efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the likelihood of reduction of error in EM practice.

Emergency Medicine↗