Standardized network order sets in rural Ontario: a follow-up report on successes and sustainability

Unifying, implementing and sustaining a large order set project requires strategic placement of key organizational professionals to provide ongoing user education, communication and support. This article will outline the successful strategies implemented by the Grey Bruce Health Network, Evidence-Based Care Program to reduce length of stay, increase patient satisfaction and increase the use of best practices resulting in quality outcomes, safer practice and better allocation of resources by using standardized Order Sets within a network of 11 hospital sites. Audits conducted in 2007 and again in 2008 revealed a reduced length of stay of 0.96 in-patient days when order sets were used on admission and readmission for the same or a related diagnosis within one month decreased from 5.5% without order sets to 3.5% with order sets.

Lessons learnt from conducting a high fidelity simulation test in health IT

Testing IT-systems by use of simulation requires a thorough planning and preparation in order to create a realistic clinical environment. For a successful test through simulation a dedicated test team to control the environment is needed, as well as people to play the role of patients and staff. Relevant artifacts and elaborate scenarios ensure the narrative. This paper explores the preliminary work and execution of an extensive test of a Computerized Order Entry System prototype. Central to the setup of the test is a script which outlines the method by guiding the preparation and execution.

Validation of completeness, correctness, relevance and understandability of the PSIP CDSS for medication safety

Medication errors and resulting Adverse Drug Events (ADEs) are an important issue of global healthcare. Within the European PSIP project that aims at developing solutions to improve medication safety, contextualized decision support modules aiming to prevent ADEs are being developed. The objective of this work was to thoroughly validate part of the CDSS (Clinical Decision Support System) and the underlying Knowledge Base, in order to detect incorrect or unclear alerts. We systematically developed a repository of test cases and used them for validation. The development of the test cases showed that there are differences among experts in interpreting the correctness of an alert, and that the clinical context is important when judging whether it is adequate. Overall, validation did not find major errors in the Knoweldge Base, but developed several recommendations for further improvement.

The future of electronic prescribing

Implementing electronic prescribing in health care has been a slow process. Health authorities are now requiring mandatory electronic prescribing because of patient safety concerns. Electronic prescribing is not yet a mature technology, and may therefore pose a risk if especially organizational conditions are not taken into account. The paper offers some thoughts on the future of electronic prescribing in practice. It is especially important to extend electronic prescribing to the continuum of care in order avoid that medication safety falls in the cracks of fragmented health care organizations.

Implementation of a taxonomy aiming to support the design of a contextualised clinical decision support system

Clinical Decision Support Systems (CDSS) are recently implemented in hospital settings to improve the reliability of drug ordering. However, such systems have limited effects due to their tendency to overalert. To healthcare professionals consider alerts, it is necessary to adapt the CDSS to their activity. Thus, it is necessary to consider contextualisation aspects in the system design. In this article, we propose a taxonomy integrating contextualisation elements issued from an activity analysis to guide the design of a contextualised CDSS. This taxonomy has been developed within the framework of the European project PSIP (Patient Safety through Intelligent Procedures in medication) aiming to make easier the identification and the prevention of Adverse Drug Events.

Three different cases of exploiting decision support services for adverse drug event prevention

Clinical Decision Support Systems (CDSSs) are implemented in clinical settings in order to improve patient outcomes and/or clinical practices. However, they are still not widely accepted by healthcare professionals due to over-alerting. The aim of the "Patient Safety through Intelligent Procedures in medication" (PSIP) project is to develop and demonstrate innovative tools so as to generate and provide relevant knowledge to healthcare professionals and patients for Adverse Drug Event (ADE) prevention by means of Information and Communication Technologies (ICT). PSIP employs a Knowledge Base (KB) as the core of its CDSS. This KB encapsulates signals capable of automatically detecting potential ADEs and contextualizing the CDSS output to the patient and healthcare professionals. To exploit the KB, a Global Knowledge Platform (GKP) has been created comprising of a KB system, a Connectivity Platform and appropriate user interface modules. The GKP has been tested to demonstrate integration of the KB in different work situations and it has been deployed in three different medical applications. The first is a Web application; the second involves a commercial French EHR (Electronic Health Record) and the third is a Danish CPOE (Computerised Physician Order Entry) system. This paper presents recent progress as regards the exploitation of the PSIP KB and the results obtained in the three different medical applications.

Facilitating access to laboratory guidelines by modeling their contents and designing a computerized user interface

Laboratory tests are not always prescribed appropriately. Guidelines for some important laboratory tests have been developed by expert panels in the Parisian region to maximize the appropriateness of laboratory medicine. However; these recommendations are not frequently consulted by physicians and nurses. We developed a system facilitating consultation of these guidelines, to increase their usability. Elements of information contained in these documents were identified and included in recommendations of different categories. UML modeling was used to represent these categories and their relationships to each other in the guidelines. We used the generated model to implement a computerized interface. The prototype interface, based on web-based technology was found to be rapid and easy to use. By clicking on provided keywords, information about the subject sought is highlighted whilst retaining the entire text of the guideline on-screen.

Information contextualization in decision support modules for adverse drug event prevention

This paper presents an analysis of hospitals' organization and Hospital Information Systems' features which can contribute in contextualization of Clinical Decision Support Systems (CDSS) for Adverse Drug Event (ADE) prevention. We identified four categories of contextualization: ENVIRONMENT, TASKS, USERS and TEMPORAL ASPECTS. Based on this analysis, we studied the technical possibilities at the architectural level to determine which component(s) of a standalone knowledge platform could technically handle contextualization. The results impact three types of components of this platform: (1) a CDSS providing decision support based on ADE signals mined in large data repositories; (2) a Connectivity Platform providing transformation and routing services (enabling any application to connect to the CDSS); (3) three prototype applications for accessing the decision support services realized within an industrial Computerized Physician Order Entry, an industrial Electronic Health Record and in an independent Web prototype, respectively. In each of the above components we present the dimension(s) of contextualization that has/have been determined to cope with and the design followed in the implementation phase.

Applying ontology techniques to develop a medication history search and alert system in department of nuclear medicine

Nowadays, patients usually take more than three drugs for diseases such as hypertension, diabetes, and dyslipidemia. Hence, nuclear medicine physicians should be very careful about the medication history of each patient and ensure that their medication will not cause false positive or false negative imaging results, because either condition will interfere with adequate treatment of the patient and result in a wrong diagnosis. The aim of the present paper is to develop an ontology-based medication search and alert system for scintiphotography of Chang Gung Memorial hospital at Kaohsiung. Composed of four sub-systems, including Medication History Collect Agent (MHCA), Medication History Search System (MHSS), Patient Medication Consultation System (PMCS), and Patient Medication Alert System (PMAS), this medication search and alert system for scintiphotography is expected to support decision making of nuclear medicine examination, improve accuracy of image reading, and offer detailed data for further research. The ultimate goal of this system is to ensure patient safety.

'Meaningful use' hoists hospital IT to next level

The winners of H & HN's annual survey of information technology use among hospitals and health systems. Plus: the Most Wired-Small and Rural, Most Improved and Most Wireless. And we consider how leaders of top IT hospitals plan to make "meaningful use" a guide for improvement.

Automated notification of suspected obstructive sleep apnea patients to the perioperative respiratory therapist: a pilot study

BACKGROUND

Obstructive sleep apnea (OSA) increases the risk of central and obstructive apneas after anesthesia, but the vast majority of patients with OSA are undiagnosed preoperatively. Current guidelines promote the use of postoperative continuous positive airway pressure (CPAP) in patients with OSA. Owing to the complex postoperative requirements of these patients, respiratory therapists (RTs) could substantially improve these patients' clinical management in the immediate postoperative period. We describe a system that identifies patients with suspected or documented OSA and automatically alerts the perioperative RT.

METHODS

Patients who presented for surgery were preoperatively assessed, and if the patient had a diagnosis of OSA or OSA risk factors, the perioperative RT automatically received a paging alert, after the surgery. The RT reviewed the patient postoperatively and instituted CPAP or bi-level positive airway pressure (BiPAP), as indicated. We collected data on triggers for the automated alerts and utilization of CPAP and BiPAP. We reviewed risk-management data to analyze the effect of this intervention on postsurgical sudden-onset acute respiratory compromise.

RESULTS

Of 7,422 patients who presented for surgery over a 5-month period, 766 had an OSA diagnosis or OSA risk factors. There were an average of 7-8 alerts per work day (range 2-18 alerts per day). On average, 2 patients per day were treated with CPAP/BiPAP in the post-anesthesia care unit or the postoperative general ward as a result of the alerts. The median paging alert time was 10:30 am. There were no episodes of sudden-onset postoperative acute respiratory compromise after institution of the OSA alert system.

CONCLUSIONS

As part of a hospital-wide postoperative policy, our automated OSA alert and perioperative RT system helped prevent sudden-onset acute respiratory compromise in postoperative patients with OSA or at risk of OSA.

Electronic interchange of lab test orders and results between laboratories reduces errors and gives full traceability

Introduction of electronic lab test ordering and reporting corresponding results between laboratories when exchanging special tests for analysis in service labs, instead of manual paper based workflow, have reduced the fault rate by a factor 10 and reduced reporting time by 2 days compared to the manual workflow. Retyping orders and results into different IT systems is not longer needed as all 9 different labsystems in more than 60 laboratories are using the same standards and procedures resulting in full interoperability. The solution, challenges, implementation process and outcome is described in the paper.

What effect does electronic ordering have on the organisational dynamics of a hospital pathology service?

The aim of this triangulated (multi-method, multi-setting, multi-staged) study was to identify the consequences of an electronic ordering system on the functioning and organisational dynamics of a hospital pathology service. The study was carried out in five pathology departments during the period August 2005 to April 2006. It included five focus groups involving 21 participants and 67 interviews with 38 participants, along with a total of 21 hours of observation. The findings revealed three key themes with implications for the functioning and organisational dynamics of the pathology service. These included: a) work process changes that affect the output of the pathology laboratories; b) temporal considerations, particularly as they related to efficiency of laboratory processes; and c) communication channels and the resulting changes in the mode of information exchange and communication. These themes emerged from a close analysis of the contextual setting of each department. Successful CPOE implementation should be premised on a solid understanding of the organisational, communication, information and temporal circumstances in which the system will operate.