Order sets in electronic health records: principles of good practice

Novel Electronic Health Records-Based Consultation Workflow Improves Time to Operating Room for Vascular Surgery Patients in an Acute Setting

BACKGROUND

Inefficient clinical workflows can have downstream effects of increased costs, poor resource utilization, and worse patient outcomes. The surgical consultation process can be complex with unclear communication, potentially delaying care for patients requiring time-sensitive intervention in an acute setting. A novel electronic health records (EHR)-based workflow was implemented to improve the consultation process. After implementation, we assessed the impact of this initiative in patients requiring vascular surgery consultation.

METHODS

An EHR-driven consultation workflow was implemented at a single institution, standardizing the process across all consulting services. This order-initiated workflow automated notification to clinicians of consult requests, communication of patient data, patient addition to consultants' lists, and tracking consult completion. Preimplementation (1/1/2020-1/31/2022) and postimplementation (2/1/2022-12/4/2022) vascular surgery consultation cohorts were compared to evaluate the impact of this initiative on timeliness of care.

RESULTS

There were 554 inpatient vascular surgery consultations (255 preimplementation and 299 postimplementation); 45 and 76 consults required surgery before and after implementation, respectively. The novel workflow resulted in placement of a consult note 32 min faster than preimplementation (preimplementation: 462 min, postimplementation: 430 min, P = 0.001) for all vascular surgery consults. Furthermore, vascular surgery patients with ASA class III or IV status requiring an urgent or emergent operation were transported to the operating room 63.3% faster after implementation of the workflow (preimplementation: 284 min, postimplementation: 180 min, P = 0.02). There were no differences in procedure duration, postoperative disposition, or intraoperative complication rates.

CONCLUSIONS

We implemented a novel workflow utilizing the EHR to standardize and automate the consultation process in the acute inpatient setting. This institutional initiative significantly improved timeliness of care for vascular surgery patients, including decreased time to operation. Innovations such as this can be further disseminated across shared EHR platforms across institutions, representing a powerful tool to increase the value of care in vascular surgery and healthcare overall.

Use of a Novel Standardized Administration Protocol Reduces Agitation Pro Re Nata (PRN) Medication Requirements: The Birmingham Agitation Management (BAM) Initiative

BACKGROUND

Agitation management is a principal challenge on inpatient psychiatric units. Overreliance on common prescribing strategies of pro re nata (PRN) medication administration is problematic, given the tendencies to have overlapping or unclear indications.

OBJECTIVE

Piloted project to determine whether a standardized protocol for agitation intervention may reduce PRN medication administration.

METHODS

The Birmingham Agitation Management (BAM) interdisciplinary team uniquely connected the Brøset Violence Checklist (BVC) for assessment of agitation severity to a standardized PRN medication order set. Nurses on the piloted unit were trained on how to score the BVC and administer medications. Patients were assessed by the BVC every 4 hours and, based on their score, would receive no medication, low-dose benzodiazepine, high-dose benzodiazepine, or high-dose benzodiazepine plus antipsychotic. The primary end point compared the number of PRNs administered after novel protocol implementation with a retrospective cohort. Secondary measures included analysis of medication-related effects, seclusion, and physical restraint rates.

RESULTS

377 patients were included in the final analyses (184 pre-BAM, 193 BAM intervention group). No significant differences were seen in patient characteristics between groups. The total number of PRNs administered decreased by 42.5%, with both the mean and median number of administrations decreasing significantly (95% confidence interval [CI] = [1.68-5.75]; P < 0.001). A trend was noted between the number of PRNs administered and seclusion rates, but did not reach statistical significance (95% CI = [-7.28 to 60.31]; P = 0.124).

CONCLUSIONS

In seemingly the first initiative of its kind, we found that a standardized agitation management protocol can help decrease the total number of PRN administrations for agitation without worsening of restraint rates and may possibly reduce the risk of adverse effects. These results require validation in specific, larger populations.

Impact of a syndrome-specific antibiotic stewardship intervention on antipseudomonal antibiotic use in inpatient diabetic foot infection management

Objective

To demonstrate that a syndromic stewardship intervention can safely reduce antipseudomonal antibiotic use in the treatment of inpatient diabetic foot infections (DFIs).

Intervention and method

From November 2017 through March 2018, we performed an antimicrobial stewardship intervention that included creation of a DFI best-practice guideline, implementation of an electronic medical record order set, and targeted education of key providers. We conducted a retrospective before-and-after study evaluating guideline adherent antipseudomonal antibiotic use 1 year before and after the intervention using interrupted time-series analysis.

Setting

University of Nebraska Medical Center, a 718-bed academic medical center in Omaha, Nebraska.

Patients

The study included 193 adults aged ≥19 years (105 in the preintervention group and 88 in the postintervention group) admitted to non-intensive care units whose primary reason for antibiotic treatment was diabetic foot infection (DFI).

Results

Guideline-adherent use of antipseudomonal antibiotics increased from 39% before the intervention to 68% after the intervention (P ≤ .0001). Antipseudomonal antibiotic use decreased from 538 days of therapy (DOT) per 1,000 DFI patient days (PD) before the intervention to 272 DOT per 1,000 DFI PD after the intervention (P < .0001), with a statistically significant decrease in both level of use and slope of change. We did not detect any changes in length of stay, readmission, amputation rate, subsequent positive Clostridioides difficile testing, or mortality.

Conclusions

Our 3-component intervention of guideline creation, implementation of an order set, and targeted education was associated with a significant decrease in antipseudomonal antibiotic use in the management of inpatient DFIs. DFIs are common and should be considered as opportunities for syndromic stewardship intervention.

Electronic Health Record-Based Decision-Making Support in Inpatient Diabetes Management

PURPOSE OF REVIEW

This review discusses ways in which the electronic health record (EHR) can offer clinical decision support (CDS) tools for management of inpatient diabetes and hyperglycemia.

RECENT FINDINGS

The use of electronic order sets can help providers order comprehensive basal bolus insulin regimens that are consistent with current guidelines. Order sets have been shown to reduce insulin errors and hypoglycemia rates. They can also help set glycemic targets, give hemoglobin A1C reminders, guide weight-based dosing, and match insulin regimen to nutritional profile. Glycemic management dashboards allow multiple variables affecting blood glucose to be shown in a single view, which allows for efficient evaluation of glucose trends and adjustment of insulin regimen. With the use glycemic management dashboards, active surveillance and remote management also become feasible. Hypoglycemia prevention and management are another part of inpatient diabetes management that is enhanced by EHR CDS tools. Furthermore, diagnosis and management of diabetic ketoacidosis and hyperglycemia hyperosmolar state are improved with the aid of EHR CDS tools. The use of EHR CDS tools helps improve the care of patients with diabetes and hyperglycemia in the inpatient hospital setting.

Hospital Adoption of Electronic Decision Support Tools for Preeclampsia Management

BACKGROUND

Electronic health record (EHR)-based clinical decision support tools can improve the use of evidence-based clinical guidelines for preeclampsia management that can reduce maternal mortality and morbidity. No study has investigated the organizational capabilities that enable hospitals to use EHR-based decision support tools to manage preeclampsia.

OBJECTIVE

To examine the association of organizational capabilities and hospital adoption of EHR-based decision support tools for preeclampsia management.

METHODS

Cross-sectional analyses of hospitals providing obstetric care in 2017. In total, 739 hospitals responded to the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS) and were linked to the 2017 American Hospital Association (AHA) Annual Survey Database and the Area Health Resources File (AHRF). A total of 425 hospitals providing obstetric care across 49 states were included in the analysis. The main outcome was whether a hospital adopted EHR-based clinical decision support tools for preeclampsia management. Hospital organizational capabilities assessed as predictors include EHR functions, adoption of evidence-based clinical treatments, use of quality improvement methods, and dissemination processes to share best patient care practices. Logistic regression estimated the association of hospital organizational capabilities and hospital adoption of EHR-based decision support tools to manage preeclampsia, controlling for hospital structural and patient sociodemographic characteristics.

RESULTS

Two-thirds of the hospitals (68%) adopted EHR-based decision support tools for preeclampsia, and slightly more than half (56%) of hospitals had a single EHR system. Multivariable regression results indicate that hospitals with a single EHR system were more likely to adopt EHR-based decision support tools for preeclampsia (17.4 percentage points; 95% CI, 1.9 to 33.0; P < .05) than hospitals with a mixture of EHR and paper-based systems. Compared with hospitals having multiple EHRs, on average, hospitals having a single EHR were also more likely to adopt the tools by 9.3 percentage points, but the difference was not statistically significant (95% CI, -1.3 to 19.9). Hospitals with more processes to aid dissemination of best patient care practices were also more likely to adopt EHR-based decision-support tools for preeclampsia (0.4 percentage points; 95% CI, 0.1 to 0.6, for every 1-unit increase in dissemination processes; P < .01).

CONCLUSION

Standardized EHRs and policies to disseminate evidence are foundational hospital capabilities that can help advance the use of EHR-based decision support tools for preeclampsia management in the approximately one-third of US hospitals that still do not use them.

[Integrated care concepts and multidisciplinary process chains in a radiological context]

Modern patient-centered and cost-efficient care concepts in hospitals require the mapping of multidisciplinary process chains into clinical pathways. Clinical decision support systems and operations research methods use algorithms to classify patients into homogeneous groups and to model a complete clinical pathway for scheduling individual procedures. An improvement of the economic situation of the care facility can be achieved through improved resource utilization, reduced patient waiting times and a shortening of the length of stay. The interdisciplinary use of centrally stored interoperable information and comprehensive care management via information technology (IT) services lay the foundation for the dissolution of traditional IT system architectures in medicine and the development of flexibly integrable modern system platforms. New IT approaches such as the semantically standardized definition of procedures and resource properties, the use of clinical decision support systems and the use of service-oriented system architectures form the basis for the deep integration of radiology services into comprehensive interdisciplinary care concepts.

Examination of a Canada-Wide Collaboration Platform for Order Sets: Retrospective Analysis

BACKGROUND

Knowledge translation and dissemination are some of the main challenges that affect evidence-based medicine. Web 2.0 platforms promote the sharing and collaborative development of content. Executable knowledge tools, such as order sets, are a knowledge translation tool whose localization is critical to its effectiveness but a challenge for organizations to develop independently.

OBJECTIVE

This paper describes a Web 2.0 resource, referred to as the collaborative network (TCN), for order set development designed to share executable knowledge (order sets). This paper also analyzes the scope of its use, describes its use through network analysis, and examines the provision and use of order sets in the platform by organizational size.

METHODS

Data were collected from Think Research's TxConnect platform. We measured interorganization sharing across Canadian hospitals using descriptive statistics. A weighted chi-square analysis was used to evaluate institutional size to share volumes based on institution size, with post hoc Cramer V score to measure the strength of association.

RESULTS

TCN consisted of 12,495 order sets across 683 diagnoses or processes. Between January 2010 and March 2015, a total of 131 health care organizations representing 360 hospitals in Canada downloaded order sets 105,496 times. Order sets related to acute coronary syndrome, analgesia, and venous thromboembolism were most commonly shared. COVID-19 order sets were among the most actively shared, adjusting for order set lifetime. A weighted chi-square analysis showed nonrandom downloading behavior (P<.001), with medium-sized institutions downloading content from larger institutions acting as the most significant driver of this variance (chi-gram=124.70).

CONCLUSIONS

In this paper, we have described and analyzed a Web 2.0 platform for the sharing of order set content with significant network activity. The robust use of TCN to access customized order sets reflects its value as a resource for health care organizations when they develop or update their own order sets.

The Value of Managing Acute Pancreatitis With Standardized Order Sets to Achieve "Perfect Care"

OBJECTIVES

We aimed to define perfect care index (PCI) metrics and to evaluate whether implementation of standardized order sets would improve outcomes without increasing hospital-based charges in patients with acute pancreatitis (AP).

METHODS

This is a retrospective, pre-post, observational study measuring clinical quality, processes of care, and hospital-based charges at a single tertiary care center. The first data set included AP patients from August 2011 to December 2014 (n = 219) before the implementation of a standardized order set (Methodist Acute Pancreatitis Protocol [MAPP]) and AP patients after MAPP implementation from January 2015 to September 2018 (n = 417). The second data set included AP patients (n = 150 in each group) from January 2013 to September 2014 (pre-MAPP) and January 2018 to September 2019 (post-MAPP) to evaluate perfect care between the 2 cohorts after controlling for systemic inflammatory response syndrome at baseline. Length of stay, PCI, and hospital-based charges were measured.

RESULTS

The post-MAPP cohort had a significantly shorter length of stay (median, 3 days vs 4 days; P = 0.01). In the second data set, PCI significantly increased after implementation of MAPP order sets (5.3%-35.3%, P < 0.0001).

CONCLUSIONS

The MAPP order sets increased the value of care by improving clinical outcomes without increasing hospital-based charges.

Lung-Protective Ventilation Over 6 Years at a Large Academic Medical Center: An Evaluation of Trends, Adherence, and Perceptions of Benefit

The main objective of this study was to evaluate trends in set tidal volumes across all adult ICUs at a large academic medical center over 6 years, with a focus on adherence to lung-protective ventilation (≤ 8-cc/kg ideal body weight). A secondary objective was to survey providers on their perceptions of lung-protective ventilation and barriers to its implementation.

DESIGN

Retrospective observational analysis (primary objective) and cross-sectional survey study (secondary objective), both at a single center.

PARTICIPANTS

Mechanically ventilated adult patients with a set tidal volume (primary objective) and providers rotating through the Medical and Neurosciences ICUs (secondary objective).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

From 2013 to 2018, the average initial set tidal volume (cc/kg ideal body weight) decreased from 8.99 ± 2.19 to 7.45±1.34 (p < 0.001). The cardiothoracic ICU had the largest change in tidal volume from 11.09 ± 1.96 in 2013 to 7.97 ± 1.03 in 2018 (p < 0.001). Although the majority of tidal volumes across all ICUs were between 6.58 and 8.01 (interquartile range) in 2018, 27% of patients were still being ventilated at volumes greater than 8-cc/kg ideal body weight. Most surveyed respondents felt there was benefit to lung-protective ventilation, though many did not routinely calculate the set tidal volume in cc/kg ideal body weight, and most did not feel it was easily calculable with the current electronic medical record system.

CONCLUSIONS

Despite a trend toward lower tidal volumes over the years, in 2018, over a quarter of mechanically ventilated adult patients were being ventilated with tidal volumes greater than 8 cc/kg. Survey data indicate that despite respondents acknowledging the benefits of lung-protective ventilation, there are barriers to its optimal implementation. Future modifications of the electronic medical record, including a calculator to set tidal volume in cc/kg and the use of default set tidal volumes, may help facilitate the delivery of and adherence to lung-protective ventilation.

Development and Optimization of Clinical Informatics Infrastructure to Support Bioinformatics at an Oncology Center

Translational bioinformatics for therapeutic discovery requires the infrastructure of clinical informatics. In this chapter, we describe the clinical informatics components needed for successful implementation of translational research at a cancer center. This chapter is meant to be an introduction to those clinical informatics concepts that are needed for translational research. For a detailed account of clinical informatics, the authors will guide the reader to comprehensive resources. We provide examples of workflows from Moffitt Cancer Center led by Drs. Perkins and Markowitz. This perspective represents an interesting collaboration as Dr. Perkins is the Chief Medical Information Officer and Dr. Markowitz is a translational researcher in Melanoma with an active informatics component to his laboratory to study the mechanisms of resistance to checkpoint blockade and an active member of the clinical informatics team.

Pediatric Post-Tonsillectomy Opioid Prescribing Practices

OBJECTIVE

To evaluate the effect of discharge order sets on prescribing patterns of opioids after pediatric tonsillectomy. Secondary outcomes included encounters for postoperative pain, dehydration, and bleeding.

METHODS

Retrospective chart review of pre- and post-intervention in pediatric post-tonsillectomy patients, 0-18 years old (n = 1486). Order sets were installed with age-specific analgesic medication defaults and recommendation of concurrent alternating scheduled ibuprofen and acetaminophen. Time-balanced pre- and post-intervention cohorts were established. Opioid outcomes calculated in morphine milligram equivalents per kilogram (MME/kg) per dosage and total prescribed.

RESULTS

Discharge order set intervention resulted in 17% reduction of opioid dose prescribed (0.095 MME/kg [95% CI, 0.092-0.099] vs. 0.079 [95% CI, 0.076-0.083], P < .001). Total number of opioid doses prescribed was reduced after order set implementation (46.4 [95% CI, 43.6-49.1] to 20.3 [95% CI, 19.1-21.5], P < .001). Patients <7 years old prescribed opioids remained rare in pre- and post-intervention groups (1.6% and 1.8%, respectively, P = .86). Admissions and emergency department visits for postoperative dehydration and pain were significantly reduced. Post-intervention group showed an increase in readmissions for post-tonsillectomy hemorrhage (9.2% vs. 5.2%, P = .003) which was isolated to an increase in the older post-intervention group after stratification by age.

CONCLUSION

Utilization of order sets with standardized analgesic medication regimen of acetaminophen, ibuprofen, and opioid helped effectively reduce opioid amount per dose, total opioid amount dispensed, and variability in the total opioid amount dispensed while maintaining pain control. An increase in post-tonsillectomy hemorrhage was recognized following this implementation which did not persist after the study period despite continuation of intervention.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1386-1391, 2021.

Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation)

Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life-threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de-escalation as a first-line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.

ClinicNet: machine learning for personalized clinical order set recommendations

OBJECTIVE

This study assesses whether neural networks trained on electronic health record (EHR) data can anticipate what individual clinical orders and existing institutional order set templates clinicians will use more accurately than existing decision support tools.

MATERIALS AND METHODS

We process 57 624 patients worth of clinical event EHR data from 2008 to 2014. We train a feed-forward neural network (ClinicNet) and logistic regression applied to the traditional problem structure of predicting individual clinical items as well as our proposed workflow of predicting existing institutional order set template usage.

RESULTS

ClinicNet predicts individual clinical orders (precision = 0.32, recall = 0.47) better than existing institutional order sets (precision = 0.15, recall = 0.46). The ClinicNet model predicts clinician usage of existing institutional order sets (avg. precision = 0.31) with higher average precision than a baseline of order set usage frequencies (avg. precision = 0.20) or a logistic regression model (avg. precision = 0.12).

DISCUSSION

Machine learning methods can predict clinical decision-making patterns with greater accuracy and less manual effort than existing static order set templates. This can streamline existing clinical workflows, but may not fit if historical clinical ordering practices are incorrect. For this reason, manually authored content such as order set templates remain valuable for the purposeful design of care pathways. ClinicNet's capability of predicting such personalized order set templates illustrates the potential of combining both top-down and bottom-up approaches to delivering clinical decision support content.

CONCLUSION

ClinicNet illustrates the capability for machine learning methods applied to the EHR to anticipate both individual clinical orders and existing order set templates, which has the potential to improve upon current standards of practice in clinical order entry.

The Impact of Changes to an Electronic Admission Order Set on Prescribing and Clinical Outcomes in the Intensive Care Unit

BACKGROUND

Implementation of disease-specific order sets has improved compliance with standards of care for a variety of diseases. Evidence of the impact admission order sets can have on care is limited.

OBJECTIVE

The main purpose of this article is to evaluate the impact of changes made to an electronic critical care admission order set on provider prescribing patterns and clinical outcomes.

METHODS

A retrospective, observational before-and-after exploratory study was performed on adult patients admitted to the medical intensive care unit using the Inpatient Critical Care Admission Order Set. The primary outcome measure was the percentage change in the number of orders for scheduled acetaminophen, a histamine-2 receptor antagonist (H2RA), and lactated ringers at admission before implementation of the revised order set compared with after implementation. Secondary outcomes assessed clinical impact of changes made to the order set.

RESULTS

The addition of a different dosing strategy for a medication already available on the order set (scheduled acetaminophen vs. as needed acetaminophen) had no impact on physician prescribing (0 vs. 0%, p = 1.000). The addition of a new medication class (an H2RA) to the order set significantly increased the number of patients prescribed an H2RA for stress ulcer prophylaxis (0 vs. 20%, p < 0.001). Rearranging the list of maintenance intravenous fluids to make lactated ringers the first fluid option in place of normal saline significantly decreased the number of orders for lactated ringers (17 vs. 4%, p = 0.005). The order set changes had no significant impact on clinical outcomes such as incidence of transaminitis, gastrointestinal bleed, and acute kidney injury.

CONCLUSION

Making changes to an admission order set can impact provider prescribing patterns. The type of change made to the order set, in addition to the specific medication changed, may have an effect on how influential the changes are on prescribing patterns.

Developing and maintaining clinical decision support using clinical knowledge and machine learning: the case of order sets

Development and maintenance of order sets is a knowledge-intensive task for off-the-shelf machine-learning algorithms alone. We hypothesize that integrating clinical knowledge with machine learning can facilitate effective development and maintenance of order sets while promoting best practices in ordering. To this end, we simulated the revision of an "AM Lab Order Set" under 6 revision approaches. Revisions included changes in the order set content or default settings through 1) population statistics, 2) individualized prediction using machine learning, and 3) clinical knowledge. Revision criteria were determined using electronic health record (EHR) data from 2014 to 2015. Each revision's clinical appropriateness, workload from using the order set, and generalizability across time were evaluated using EHR data from 2016 and 2017. Our results suggest a potential order set revision approach that jointly leverages clinical knowledge and machine learning to improve usability while updating contents based on latest clinical knowledge and best practices.

Formative Usability Testing Reduces Severe Blood Product Ordering Errors

BACKGROUND

Medical errors in blood product orders and administration are common, especially for pediatric patients. A failure modes and effects analysis in our health care system indicated high risk from the electronic blood ordering process.

OBJECTIVES

There are two objectives of this study as follows:(1) To describe differences in the design of the original blood product orders and order sets in the system (original design), new orders and order sets designed by expert committee (DEC), and a third-version developed through user-centered design (UCD).(2) To compare the number and type of ordering errors, task completion rates, time on task, and user preferences between the original design and that developed via UCD.

METHODS

A multidisciplinary expert committee proposed adjustments to existing blood product order sets resulting in the DEC order set. When that order set was tested with front-line users, persistent failure modes were detected, so orders and order sets were redesigned again via formative usability testing. Front-line users in their native clinical workspaces were observed ordering blood in realistic simulated scenarios using a think-aloud protocol. Iterative adjustments were made between participants. In summative testing, participants were randomized to use the original design or UCD for five simulated scenarios. We evaluated differences in ordering errors, time on task, and users' design preference with two-sample t-tests.

RESULTS

Formative usability testing with 27 providers from seven specialties led to 18 changes made to the DEC to produce the UCD. In summative testing, error-free task completion for the original design was 36%, which increased to 66% in UCD (30%, 95% confidence interval [CI]: 3.9-57%; p = 0.03). Time on task did not vary significantly.

CONCLUSION

UCD led to substantially different blood product orders and order sets than DEC. Users made fewer errors when ordering blood products for pediatric patients in simulated scenarios when using the UCD orders and order sets compared with the original design.

Neurological Dashboards and Consultation Turnaround Time at an Academic Medical Center

BACKGROUND

Neurologists perform a significant amount of consultative work. Aggregative electronic health record (EHR) dashboards may help to reduce consultation turnaround time (TAT) which may reflect time spent interfacing with the EHR.

OBJECTIVES

This study was aimed to measure the difference in TAT before and after the implementation of a neurological dashboard.

METHODS

We retrospectively studied a neurological dashboard in a read-only, web-based, clinical data review platform at an academic medical center that was separate from our institutional EHR. Using our EHR, we identified all distinct initial neurological consultations at our institution that were completed in the 5 months before, 5 months after, and 12 months after the dashboard go-live in December 2017. Using log data, we determined total dashboard users, unique page hits, patient-chart accesses, and user departments at 5 months after go-live. We calculated TAT as the difference in time between the placement of the consultation order and completion of the consultation note in the EHR.

RESULTS

By April 30th in 2018, we identified 269 unique users, 684 dashboard page hits (median hits/user 1.0, interquartile range [IQR] = 1.0), and 510 unique patient-chart accesses. In 5 months before the go-live, 1,434 neurology consultations were completed with a median TAT of 2.0 hours (IQR = 2.5) which was significantly longer than during 5 months after the go-live, with 1,672 neurology consultations completed with a median TAT of 1.8 hours (IQR = 2.2; p = 0.001). Over the following 7 months, 2,160 consultations were completed and median TAT remained unchanged at 1.8 hours (IQR = 2.5).

CONCLUSION

At a large academic institution, we found a significant decrease in inpatient consult TAT 5 and 12 months after the implementation of a neurological dashboard. Further study is necessary to investigate the cognitive and operational effects of aggregative dashboards in neurology and to optimize their use.

SuperOrder: Provider order recommendation system for outpatient clinics

This study aims at developing SuperOrder, an order recommendation system for outpatient clinics. Using the electronic health record data available at midnight, SuperOrder predicts the order contents for each upcoming appointment on a daily basis. A two-level prediction framework is proposed. At the base-level, the predictions are produced by aggregating three machine learning methods. The meta-level predictions are generated by integrating the base-level predictions with the order co-occurrence network. We used the retrospective data between 1 April 2014 and 31 March 2015 in pulmonary clinics from five hospital sites within a large rural health care facility in Pennsylvania to test the feasibility. With a decrease of 6 per cent in the precision, the improvement of the recall at the meta-level is approximately 20 per cent from the base-level. This demonstrates that the proposed order co-occurrence network helps in increasing the performance of order predictions. The implementation will bring a more effective and efficient way to place outpatient orders.

Effectiveness of standardised preoperative assessment and patient instructions on admission blood glucose for patients with diabetes undergoing orthopaedic surgery at a tertiary referral hospital

Diabetes and hyperglycaemia affect a significant number of people and are associated with a variety of untoward effects, especially under physiological stress such as surgery. Due, in large part to limited evidence, clinical practice in monitoring blood glucose and treating hyperglycaemic conditions in the perioperative period is variable. We used Lean methodologies to implement a standardised approach to preoperative management of patients undergoing elective surgery in an effort to improve glycaemic control. Overall, we saw an appropriate increase in monitoring and a decrease in the rate of hyperglycaemia on presentation to the operating room. This approach may be useful in other care settings or patient populations, potentially contributing to improved glycaemic control and subsequent decrease in associated complications.

Medication therapy disease management: Geisinger's approach to population health management

PURPOSE

Pharmacists' involvement in a population health initiative focused on chronic disease management is described.

SUMMARY

Geisinger Health System has cultivated a culture of innovation in population health management, as highlighted by its ambulatory care pharmacy program, the Medication Therapy Disease Management (MTDM) program. Initiated in 1996, the MTDM program leverages pharmacists' pharmacotherapy expertise to optimize care and improve outcomes. MTDM program pharmacists are trained and credentialed to manage over 16 conditions, including atrial fibrillation (AF) and multiple sclerosis (MS). Over a 15-year period, Geisinger Health Plan (GHP)-insured patients with AF whose warfarin therapy was managed by the MTDM program had, on average, 18% fewer emergency department (ED) visits and 18% fewer hospitalizations per year than GHP enrollees with AF who did not receive MTDM services, with 23% lower annual total care costs. Over a 2-year period, GHP-insured patients with MS whose pharmacotherapy was managed by pharmacists averaged 28% fewer annual ED visits than non-pharmacist-managed patients; however, the mean annual total care cost was 21% higher among MTDM clinic patients.

CONCLUSION

The Geisinger MTDM program has evolved over 20 years from a single pharmacist-run anticoagulation clinic into a large program focused on managing the health of an ever-growing population. Initial challenges in integrating pharmacists into the Geisinger patient care framework as clinical experts were overcome by demonstrating the MTDM program's positive impact on patient outcomes.

Altering standard admission order sets to promote clinical laboratory stewardship: a cohort quality improvement study

BACKGROUND

Careful design of preprinted order sets is needed to prevent medical overuse. Recent work suggests that removing a single checkbox from an order set changes physicians' clinical decision-making.

LOCAL PROBLEM

During a 2-month period, our coronary care unit (CCU) ordered almost eight times as many serum thyroid-stimulating hormone (TSH) tests as our neighbouring intensive care unit, many without a reasonable clinical basis. We postulated that we could reduce inappropriate testing and improve clinical laboratory stewardship by removing the TSH checkbox from the CCU admission order set.

METHODS

After we retrospectively evaluated CCU TSH ordering before intervention, the checkbox was removed from the CCU admission order set. Twelve weeks later, we commenced a prospective 2-month assessment of TSH testing and clinical sequelae of thyroid disease among all CCU admissions. If clinical indications were absent or testing had occurred within 6 weeks, TSH requests were labelled as 'inappropriate'.

RESULTS

Physician ordering and, specifically, inappropriate ordering decreased substantially after the intervention. In 2016 among physician-ordered TSH tests, 60.6% (66/109) were inappropriate; in 2017 this decreased to 20% (2/10, p=0.01). Overall, the net effect of checkbox removal saw the decrease in TSH testing without clinical indication outweigh an increase in missed testing where indications appear to exist.

CONCLUSIONS

Provision of an optional checkbox for a laboratory test in an admission order set can promote overuse of laboratory resources. Simple removal of a checkbox may dramatically change test ordering patterns and promote clinical laboratory stewardship. Given our reliance on order sets, particularly by trainees, changes to order sets must be cautious to assure guideline-directed care is maintained.

Value-Based Health Care in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic inflammatory disease associated with significant resource utilization and health care burden. It is emerging as a global disease affecting an increasing proportion of the population. Along with evolving epidemiological trends, the paradigm of managing IBD has also changed. With a burgeoning repertoire of therapeutic options, improved use of health informatics, and emphasis on health care value, the treatment paradigm for IBD has experienced seismic shifts. In this review, we focused on value-based health care (VBHC)-a health care model that emphasizes monitoring outcomes to emphasize patient-centered, cost-effective IBD patient care. Several quality initiatives have been developed worldwide, and successful models of care were created for proper implementation of these initiatives. Although there are significant challenges to scale these models to a national level, it is still possible to successfully implement VBHC models within health systems to improve the quality of care provided to patients with IBD.

Safety and Usability Guidelines of Clinical Information Systems Integrating Clinical Workflow: A Systematic Review

Objectives

The usability of clinical information systems (CISs) is known to be an essential consideration in ensuring patient safety as well as integrating clinical flow. This study aimed to determine how usability and safety guidelines of CIS consider clinical workflow through a systematic review in terms of the target systems, methodology, and guideline components of relevant articles.

Methods

A literature search was conducted for articles published from 2000 to 2015 in PubMed, Cochrane, EMBASE, Web of Science, and CINAHL. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement method was employed. Articles containing recommendations, principles, and evaluation items for CIS usability and safety were included. The selected articles were classified according to article type, methodology, and target systems. Taking clinical workflow into consideration, the components of guidelines were extracted and classified.

Results

A total of 7,401 articles were identified by keyword search. From the 76 articles remaining after abstract screening, 15 were selected through full-text review. Literature review (n = 7) was the most common methodology, followed by expert opinions (n = 6). Computerized physician order entry (n = 6) was the most frequent system. Four articles considered the entire process of clinical tasks, and two articles considered the principles of the entire process of user interface affecting clinical workflow. Only two articles performed heuristic evaluations of CISs.

Conclusions

The usability and safety guidelines of CISs need improvement in guideline development methodology and with consideration of clinical workflow.

Path of least resistance: how computerised provider order entry can lead to (and reduce) wasteful practices

Background

Computerised provider order entry (CPOE) is rapidly becoming the mainstay in clinical care and has the potential to improve provider efficiency and accuracy. However, this hinges on careful planning and implementation. Poorly planned CPOE order sets can lead to undetected errors and waste. In our emergency department (ED), lactate dehydrogenase (LDH) was bundled into various blood work panels but had little clinical value.

Objectives

This quality improvement initiative aimed to reduce unnecessary LDH testing in the ED.

Methods

A group of ED physicians reviewed CPOE blood work panels and uncoupled LDH in conditions where it was deemed not to provide any clinically useful information. We measured the daily number of LDH tests performed before and after its removal. We tracked the frequency of other serum tests as controls. We also analysed the number of add-on LDH (ie, to add LDH to samples already sent to the lab) as a balancing measure, since this can disrupt work flow and delay care.

Results

Through this intervention, we reduced the number of LDH tests performed by 69%, from an average of 75.1 tests per day to 23.2 (P<0.0005). The baseline controls did not differ after the intervention (eg, a complete blood count was performed 197.7 and 196.1 times per day preintervention and postintervention, respectively (P=0.7663)). There was less than one add-on LDH per day on average.

Conclusions

CPOE care templates can be powerful in shaping behaviours and reducing variability. However, close oversight of these panels is necessary to prevent errors and waste.

Routine Indwelling Urethral Catheterization in Acute Heart Failure Patients Is Associated With Increased Urinary Tract Complications Without Improved Heart Failure Outcomes

BACKGROUND

Indwelling urethral catheters (IUC) are routinely inserted for the purpose of monitoring urine output in patients with acute heart failure (AHF). The benefit of IUC in patients capable of complying with urine collection protocols is unclear, and IUC carry multiple risks. This study describes the impact of IUC on AHF treatment.Methods and Results:A total of 540 records were retrospectively analyzed. After exclusion criteria were applied, 316 patients were propensity matched to establish groups of 100 AHF patients who either did (IUC(+)) or did not receive an IUC (IUC(-)) upon admission. Hospital length of stay (9 vs. 7 days), in-hospital urinary complications (24 vs. 5%), and 1-year urinary tract infection rate (17 vs. 6%; HR, 3.145; 95% CI: 1.240-7.978) were significantly higher in the IUC(+) group (P<0.05 for all). There were no differences in 30-day rehospitalization (6 vs. 6%; HR, 0.981; 95% CI: 0.318-3.058; P=0.986) or major adverse cardiac/cerebrovascular events at 1 year (37 vs. 32%, HR, 1.070; 95% CI: 0.636-1.799; P=0.798).

CONCLUSIONS

Based on this retrospective analysis, the routine use of IUC may increase length of stay and UTI complications in AHF patients without reducing the risk for major cardiovascular and cerebrovascular events or 30-day rehospitalization rate.

Transfusion Thresholds for Major Orthopedic Surgery: A Systematic Review and Meta-analysis

BACKGROUND

More than a million surgeries are performed annually in the United States for hip or knee arthroplasty or hip fracture stabilization. One-fifth of these patients have blood transfusions during their hospital stay. Increases in transfusion rates have caused concern about increased adverse events from unnecessary transfusions.

METHODS

We systematically reviewed randomized trials examining the effect of restrictive vs liberal transfusion thresholds on patients having major orthopedic surgery. Study results were meta-analyzed with a random-effects model and heterogeneity was tested with the I² statistic. Study risk of bias was assessed using a modified Jadad scale and evidence strength was measured using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system.

RESULTS

A total of 504 published articles were screened, and 15 met inclusion criteria. The articles described 9 randomized trials, most comparing transfusion thresholds of 8 vs 10 g/dL hemoglobin. All involved hip or knee arthroplasty and/or hip fracture patients. Moderate-strength evidence suggested a reduction in need for transfusion (relative risk, 0.53; 95% confidence interval [CI], 0.39-0.71; I² = 95%) and mean number of units transfused (-0.95 units, 95% CI, -1.48 to -0.41, I² = 98%). There was a possible reduction in overall infections with more restrictive transfusion thresholds, although the result was not statistically significant (relative risk, 0.71; 95% CI, 0.47-1.06; I² = 54%). Moderate-strength evidence suggested no differences in other clinical outcomes between the groups. Limitations included incomplete blinding, inconsistency, and imprecision.

CONCLUSION

Moderate-strength evidence suggests that restrictive transfusion practices reduce utilization of transfusions and may decrease infections without increasing adverse outcomes in major orthopedic surgery.

Effectiveness of a multi-component quality improvement intervention on rates of hyperglycaemia

Purpose

To evaluate the effectiveness of a multifaceted, hospital-wide glycaemic control quality improvement programme.

Methods

The quality improvement intervention comprised three components, derived through root cause analysis: standardising and simplifying care (including evidence-based order sets), increasing visibility (through provider access to clinical data and direct feedback) and educational outreach (directed at the entire institution). Effectiveness was determined at a single urban acute care hospital through time-series analysis with statistical process control charts. Primary outcomes included rate of hyperglycaemia and rate of hypoglycaemia.

Results

The study included 70 992 hospital admissions for 50 404 patients, with 3 35 645 patient days. The hyperglycaemia ratio decreased 25.2% from 14.1% to 10.5% (95% CI 3.3 to 3.9 percentage points, p<0.001). The ratio of patient days with highly elevated blood glucose (>299 mg/dL) decreased 31.8% from 4.8% to 3.3% (95% CI 1.4 to 1.7 percentage points, p<0.001). Hypoglycaemia ratio decreased from 5.2% to 4.6% (95% CI 0.27 to 0.89 percentage points, p<0.001) in patients with diabetes, but increased in patients without diabetes from 1.2% to 1.7% (95% CI 0.46 to 0.70 percentage points, p<0.001).

Conclusions

We demonstrate improved hospital-wide glycaemic control after a multifaceted quality improvement intervention in the context of strong institutional commitment, national mentorship and Lean management

A content analysis of electronic health record (EHR) functionality to support tobacco treatment

Government regulations have created new incentives for health systems to implement changes in electronic health records (EHRs) to reduce tobacco use among patients. The purpose of this study is to conduct a content analysis of EHR modifications aimed at supporting tobacco cessation and to document these modifications using a 5 A's framework (i.e., Ask, Advise, Assess, Assist, Arrange). Fourteen trials were identified that met inclusion criteria. A content analysis of EHR functionality in these trials was conducted by two independent reviewers between February and June 2015. For "Ask," all trials provided for the documentation of smoking status in the EHR. For "Advise," 35.7 % of EHRs provided functionality related to helping a clinician provide advice to quit. For "Assess," more than half (57.1 %) of EHRs included a feature to document a patient's willingness to quit. For "Assist," EHRs offered features for medication prescribing (78.6 %), providing educational materials to patients (57.1 %), referring a patient to the quitline (50.0 %), referring a patient to a tobacco treatment specialist (42.9 %), and documenting the provision of counseling (35.7 %). Finally, for "Arrange," EHRs supported the following up of patients (35.7 %) and allowed tobacco treatment specialists to "pass back" patient notes to primary care providers (28.6 %). Studies that have modified EHRs for tobacco treatment have done so across the steps in the 5 As model, with most modifications occurring to support documenting smoking status (Ask) and assisting with medication prescribing (Assist). As health systems attempt to comply with Meaningful Use regulations, an understanding of the range of EHR modifications to support tobacco treatment is warranted.

Diagnostic assessment of skeletal maturity through dental maturation in Hispanic growing individuals

Background

The aim of this study was to explore dental maturation as a diagnostic test for skeletal maturation.

Materials and Methods

Six hundred and fifty-seven growing individuals were classified according to their cervical vertebral maturity and dental maturity, both determined in lateral cephalograms and panoramic radiographs, respectively. The correlation between cervical and dental stages was established for each gender. A receiver operating characteristic curve analysis was made, and sensitivity and specificity values were established.

Results

Correlation was found between cervical and dental maturation for females (r = 0.73; P < 0.001) and males (r = 0.60; P < 0.001). Sensitivity for dental Stage F, as an indicator of a postmaturation peak stage, was 87.21% for females and 97.1% for males, whereas specificity for the same stage was 82.92% and 72.3% for females and males, respectively.

Conclusions

Dental maturation evaluation could contribute determining whether a patient is in a pre- or post-growth spurt stage.

Using lean methodology to improve efficiency of electronic order set maintenance in the hospital

Order sets, a series of orders focused around a diagnosis, condition, or treatment, can reinforce best practice, help eliminate outdated practice, and provide clinical guidance. However, order sets require regular updates as evidence and care processes change. We undertook a quality improvement intervention applying lean methodology to create a systematic process for order set review and maintenance. Root cause analysis revealed challenges with unclear prioritization of requests, lack of coordination between teams, and lack of communication between producers and requestors of order sets. In March of 2014, we implemented a systematic, cyclical order set review process, with a set schedule, defined responsibilities for various stakeholders, formal meetings and communication between stakeholders, and transparency of the process. We first identified and deactivated 89 order sets which were infrequently used. Between March and August 2014, 142 order sets went through the new review process. Processing time for the build duration of order sets decreased from a mean of 79.6 to 43.2 days (p<.001, CI=22.1, 50.7). Applying Lean production principles to the order set review process resulted in significant improvement in processing time and increased quality of orders. As use of order sets and other forms of clinical decision support increase, regular evidence and process updates become more critical.

Evidence synthesis activities of a hospital evidence-based practice center and impact on hospital decision making

BACKGROUND

Hospital evidence-based practice centers (EPCs) synthesize and disseminate evidence locally, but their impact on institutional decision making is unclear.

OBJECTIVE

To assess the evidence synthesis activities and impact of a hospital EPC serving a large academic healthcare system.

DESIGN, SETTING, AND PARTICIPANTS

Descriptive analysis of the EPC's database of rapid systematic reviews since EPC inception (July 2006-June 2014), and survey of report requestors from the EPC's last 4 fiscal years.

MEASUREMENTS

Descriptive analyses examined requestor and report characteristics; questionnaire examined report usability, impact, and requestor satisfaction (higher scores on 5-point Likert scales reflected greater agreement).

RESULTS

The EPC completed 249 evidence reviews since inception. The most common requestors were clinical departments (29%, n = 72), chief medical officers (19%, n = 47), and purchasing committees (14%, n = 35). The most common technologies reviewed were drugs (24%, n = 60), devices (19%, n = 48), and care processes (12%, n = 31). Mean report completion time was 70 days. Thirty reports (12%) informed computerized decision support interventions. More than half of reports (56%, n = 139) were completed in the last 4 fiscal years for 65 requestors. Of the 64 eligible participants, 46 responded (72%). Requestors were satisfied with the report (mean = 4.4), and agreed it was delivered promptly (mean = 4.4), answered the questions posed (mean = 4.3), and informed their final decision (mean = 4.1).

CONCLUSIONS

This is the first examination of evidence synthesis activities by a hospital EPC in the United States. Our findings suggest hospital EPCs can efficiently synthesize and disseminate evidence addressing a range of clinical topics for diverse stakeholders, and can influence local decision making.

An occult finding in heparin drip order set

BACKGROUND

In 1998, the Institute of Medicine (IOM) noted that the American healthcare system had many problems. A major concern was the pervasiveness of medical errors. Electronic medical records (EMR) were introduced for myriad of reasons, one being to reduce these errors. Within the EMR, order sets have been shown to reduce variation in clinical practice and improve the quality of care. However, the lack of standardization in these sets enables peculiar orders, such as fecal occult blood test (FOBT) in the heparin drip order set at our hospital, to be surprisingly included. Our study was conducted to evaluate the consequences associated with having FOBT in this order set.

METHODS

A retrospective study of 898 adult hospitalized patients over a 6-month period, who had a heparin drip ordered at a single academic center, was conducted. The main focus of our study was the 130 patients for whom the FOBT was sent.

RESULTS

Fifteen percent (n=130) of patients started on IV heparin had FOBT sent, of which 33 (25%) came back positive. Approximately one-third (36%) of the positive results were documented by a provider, either in a progress note or discharge summary. In eight instances of a positive FOBT (24%), the heparin drip was stopped. For 10 patients with a positive test (30%), gastroenterology was consulted, and 4 (12%) patients had inpatient endoscopy. Five patients with positive FOBT died while in the hospital (15%) as compared to seven patients (7%) in the negative FOBT group, p<0.05.

CONCLUSIONS

Most patients started on heparin did not have FOBT tested, and the results changed management infrequently, even when positive. The regular review of all order sets is imperative to ensure that they remain evidenced-based and sensible.

Electronic health records: current and future use

This paper provides an overview of the current state of the electronic medical record, including benefits and shortcomings, and presents key factors likely to drive development in the next decade and beyond. The current electronic medical record to a large extent represents a digital version of the traditional paper legal record, owned and maintained by the practitioner. The future electronic health record is expected to be a shared tool, engaging patients in decision making, wellness and disease management and providing data for individual decision support, population management and analytics. Many drivers will determine this path, including payment model reform, proliferation of mobile platforms, telemedicine, genomics and individualized medicine and advances in 'big data' technologies.

Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation

RATIONALE

Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics.

METHODS

This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and (3) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate.

RESULTS

Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% confidence interval [CI], 1.05-1.39; P < 0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI, 1.08-1.21; P < 0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P < 0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall odds ratio of delirium was 0.67 (95% CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction in median duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95% CI, 0.80-1.76; P = 0.40) was seen.

CONCLUSIONS

Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.

Potential Social, Environmental, and Regulatory Threats to Electronic Health Record Strategies for Improving Tobacco Treatment in Healthcare

Introduction– The potential impact of electronic health records (EHR) in driving tobacco treatment behaviours within healthcare settings has been established. However, little is known about the administrative variables that may undermine effectiveness in real world settings.

Aims– Assist healthcare planners interested in implementing tobacco-EHR systems by identifying an EHR framework that is consistent with published treatment guidelines, and the important organisational variables that can undermine the effectiveness of tobacco-EHR.

Methods– This paper considers the established literature on EHR implementation and physician behaviour change, and integrates this understanding with the observations of an expert workgroup tasked with facilitating tobacco-EHR implementation in Southeastern Pennsylvania.

Results/ Findings– System change in this topic area will continue to be problematic unless attention is paid to several important lessons regarding: 1) the evolving healthcare regulatory environment, 2) the integration of tobacco use treatment into primary care, and 3) the existing social and organisational barriers to uptake of evidence-based recommendations.

Conclusion– Healthcare organisations seeking to reduce the impact of tobacco use on their patients are well served by tobacco-EHR systems that improve care. Managers can avoid sub-optimal implementation by considering several threats to effectiveness before proceeding to systems change.

Interventions and targets aimed at improving quality in inflammatory bowel disease ambulatory care

Over the past decade, there has been increasing focus on improving the quality of healthcare delivered to patients with chronic diseases, including inflammatory bowel disease. Inflammatory bowel disease is a complex, chronic condition with associated morbidity, health care costs, and reductions in quality of life. The condition is managed primarily in the outpatient setting. The delivery of high quality of care is suboptimal in several ambulatory inflammatory bowel disease domains including objective assessments of disease activity, the use of steroid-sparing agents, screening prior to anti-tumor necrosis factor therapy, and monitoring thiopurine therapy. This review outlines these gaps in performance and provides potential initiatives aimed at improvement including reimbursement programs, quality improvement frameworks, collaborative efforts in quality improvement, and the use of healthcare information technology.

Quality of care delivered to hospitalized inflammatory bowel disease patients

Hospitalized patients with inflammatory bowel disease (IBD) are at high risk for morbidity, mortality, and health care utilization costs. While the literature on trends in hospitalization rates for this disease is conflicting, there does appear to be significant variation in the delivery of care to this complex group, which may be a marker of suboptimal quality of care. There is a need for improvement in identifying patients at risk for hospitalization in an effort to reduce admissions. Moreover, appropriate screening for a number of hospital acquired complications such as venous thromboembolism and Clostridium difficile infection is suboptimal. This review discusses areas of inpatient care for IBD patients that are in need of improvement and outlines a number of potential quality improvement initiatives such as pay-for-performance models, quality improvement frameworks, and healthcare information technology.

The effects of on-screen, point of care computer reminders on processes and outcomes of care

BACKGROUND

The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'.

OBJECTIVES

To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care.

SEARCH STRATEGY

We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles.

SELECTION CRITERIA

Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome.

MAIN RESULTS

Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

AUTHORS' CONCLUSIONS

Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.