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Talmon J, Ash JS, Bates DW, Beuscart-Zéphir MC, Duhamel A, Elkin PL, Gardner RM, Geissbuhler A, Ammenwerth E. Impact of CPOE on Mortality Rates – Contradictory Findings, Important Messages. Methods Inf Med 2018. [DOI: 10.1055/s-0038-1634123] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Summary
Objective:
To analyze the seemingly contradictory results of the Han study (Pediatrics 2005) and the Del Beccaro study (Pediatrics 2006), both analyzing the effect of CPOE systems on mortality rates in pediatric intensive care settings.
Methods:
Seven CPOE system experts from the United States and Europe comment on these papers.
Results:
The two studies are not contradictory, but almost non-comparable due to differences in design and implementation. They demonstrate the range of outcomes that can be obtained from introducing informatics applications in complex health care settings. Implementing informatics applications is a socio-technical activity, which often depends more on the organizational context than on a specific technology. As health informaticians, we must not only learn from failures, but also avoid both uncritical scepticism that may arise from drawing overly general conclusions from one negative trial, as much as uncritical optimism from limited successful ones.
Conclusion:
The commentaries emphasize the need to promote systematic studies for assessing the socio-technical factors that influence the introduction of increasingly sophisticated informatics applications within complex organizations. The emergence of evidence-based health informatics will be based both on evaluation guidelines and implementation guidelines, both of which increase the chances of successful implementation. In addition, well-educated health informaticians are needed to manage and guide the implementation processes.
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Bates DW, Baysari MT, Dugas M, Haefeli WE, Kushniruk AW, Lehmann CU, Liu J, Mantas J, Margolis A, Miyo K, Nohr C, Peleg M, de Quirós FGB, Slight SP, Starmer J, Takabayashi K, Westbrook JI. Discussion of “Attitude of Physi -cians Towards Automatic Alerting in Computerized Physician Order Entry Systems”. Methods Inf Med 2018. [DOI: 10.1055/s-0038-1627055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
With these comments on the paper “Attitude of Physicians Towards Automatic Alerting in Computerized Physician Order Entry Systems”, written by Martin Jung and co authors, with Dr. Elske Ammenwerth as senior author [1], the journal wants to stimulate a broad discussion on computerized physi cian order entry systems. An international group of experts have been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.
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Zhou L, Dhopeshwarkar N, Blumenthal KG, Goss F, Topaz M, Slight SP, Bates DW. Drug allergies documented in electronic health records of a large healthcare system. Allergy 2016; 71:1305-13. [PMID: 26970431 DOI: 10.1111/all.12881] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The prevalence of drug allergies documented in electronic health records (EHRs) of large patient populations is understudied. OBJECTIVE We aimed to describe the prevalence of common drug allergies and patient characteristics documented in EHRs of a large healthcare network over the last two decades. METHODS Drug allergy data were obtained from EHRs of patients who visited two large tertiary care hospitals in Boston from 1990 to 2013. The prevalence of each drug and drug class was calculated and compared by sex and race/ethnicity. The number of allergies per patient was calculated and the frequency of patients having 1, 2, 3…, or 10+ drug allergies was reported. We also conducted a trend analysis by comparing the proportion of each allergy to the total number of drug allergies over time. RESULTS Among 1 766 328 patients, 35.5% of patients had at least one reported drug allergy with an average of 1.95 drug allergies per patient. The most commonly reported drug allergies in this population were to penicillins (12.8%), sulfonamide antibiotics (7.4%), opiates (6.8%), and nonsteroidal anti-inflammatory drugs (NSAIDs) (3.5%). The relative proportion of allergies to angiotensin-converting enzyme (ACE) inhibitors and HMG CoA reductase inhibitors (statins) have more than doubled since early 2000s. Drug allergies were most prevalent among females and white patients except for NSAIDs, ACE inhibitors, and thiazide diuretics, which were more prevalent in black patients. CONCLUSION Females and white patients may be more likely to experience a reaction from common medications. An increase in reported allergies to ACE inhibitors and statins is noteworthy.
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Affiliation(s)
- L. Zhou
- Division of General Internal Medicine and Primary Care; Brigham and Women's Hospital; Boston MA USA
- Clinical Informatics; Partners eCare; Partners HealthCare System; Boston MA USA
- Harvard Medical School; Boston MA USA
| | - N. Dhopeshwarkar
- Division of General Internal Medicine and Primary Care; Brigham and Women's Hospital; Boston MA USA
| | - K. G. Blumenthal
- Allergy and Immunology; Massachusetts General Hospital; Boston MA USA
| | - F. Goss
- Department of Emergency Medicine; University of Colorado; Aurora CO USA
| | - M. Topaz
- Division of General Internal Medicine and Primary Care; Brigham and Women's Hospital; Boston MA USA
- Harvard Medical School; Boston MA USA
| | - S. P. Slight
- Division of General Internal Medicine and Primary Care; Brigham and Women's Hospital; Boston MA USA
- Division of Pharmacy; School of Medicine; Pharmacy and Health; Durham University; Durham UK
| | - D. W. Bates
- Division of General Internal Medicine and Primary Care; Brigham and Women's Hospital; Boston MA USA
- Harvard Medical School; Boston MA USA
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Emani S, Ting DY, Healey M, Lipsitz SR, Ramelson H, Suric V, Bates DW. Physician Perceptions and Beliefs about Generating and Providing a Clinical Summary of the Office Visit. Appl Clin Inform 2015; 6:577-90. [PMID: 26448799 DOI: 10.4338/aci-2015-04-ra-0043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/25/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A core measure of the meaningful use of EHR incentive program is the generation and provision of the clinical summary of the office visit, or the after visit summary (AVS), to patients. However, little research has been conducted on physician perceptions and beliefs about the AVS. OBJECTIVES Evaluate physician perceptions and beliefs about the AVS and the effect of the AVS on workload, patient outcomes, and the care the physician delivers. METHODS A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who are participating in the meaningful use EHR incentive program. RESULTS Of the 1 795 physicians at both AMCs participating in the incentive program, 853 completed the survey for a response rate of 47.5%. Eighty percent of the respondents reported that the AVS was easy (very easy or quite easy or somewhat easy) to generate and provide to patients. Nonetheless, more than three-fourths of the respondents reported a negative effect of generating and providing the AVS on workload of office staff (78%) and workload of physicians (76%). Primary care physicians had more positive beliefs about the effect of the AVS on patient outcomes than specialists (p<0.001) and also had more positive beliefs about the effect of the AVS on the care they delivered than specialists (p<0.001). CONCLUSIONS Achieving the core meaningful use measure of generating and providing the AVS was easy for physicians but it did not necessarily translate into positive beliefs about the effect of the AVS on patient outcomes or the care the physician delivered. Physicians also had negative beliefs about the effect of the AVS on workload. To promote positive beliefs among physicians around the AVS, organizations should obtain physician input into the design and implementation of the AVS and develop strategies to mitigate its negative impacts on workload.
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Affiliation(s)
- S Emani
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States
| | - D Y Ting
- Massachusetts General Physicians Organization, Massachusetts General Hospital , Boston,MA, United States
| | - M Healey
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States ; Brigham and Women's Physician Organization, Brigham and Women's Hospital , Boston, MA, United States
| | - S R Lipsitz
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States
| | - H Ramelson
- Information Services, Partners HealthCare , Boston, MA, United States
| | - V Suric
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States
| | - D W Bates
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States ; Department of Healthcare Policy and Management, Harvard School of Public Health , Boston, MA, United States
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Abstract
The costs of care in the U.S. are very high, in part because canre is relatively uncoordinated. To begin to address this and other issues, health care reform was passed, including the notion of accountable care. Under acountable care arrangements, providers are at risk for the costs of the care they provide to groups of patients. Evaluation of costs has made it clear that a large proportion of these costs are in the post-acute setting, and also that many specific problems such as adverse events and unnecessary readmissions occur following transitions. However, the electronic health records of today do not provide a great deal of assistance with the coordination of care, and even the best organizations have relatively primitive systems with respect to care coordination, even though communication is absolutely central to better coordination of care and health information technology (HIT) is a powerful lever for improving communication. This paper identifies specific gaps in care coordination today, presents a framework for better coordinating care using HIT, then describes how specific technologies can be leveraged. Also discussed are the need to build and test specific interventions to improve HIT-related care coordination tools, and the key policy steps needed to accomplish this.
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Affiliation(s)
- D W Bates
- David Bates, Division of General Internal Medicine, 1620 Tremont St., Boston, MA 02115, United States of America, E-mail:
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6
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Abstract
The costs of care in the U.S. are very high, in part because canre is relatively uncoordinated. To begin to address this and other issues, health care reform was passed, including the notion of accountable care. Under acountable care arrangements, providers are at risk for the costs of the care they provide to groups of patients. Evaluation of costs has made it clear that a large proportion of these costs are in the post-acute setting, and also that many specific problems such as adverse events and unnecessary readmissions occur following transitions. However, the electronic health records of today do not provide a great deal of assistance with the coordination of care, and even the best organizations have relatively primitive systems with respect to care coordination, even though communication is absolutely central to better coordination of care and health information technology (HIT) is a powerful lever for improving communication. This paper identifies specific gaps in care coordination today, presents a framework for better coordinating care using HIT, then describes how specific technologies can be leveraged. Also discussed are the need to build and test specific interventions to improve HIT-related care coordination tools, and the key policy steps needed to accomplish this.
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Affiliation(s)
- D W Bates
- David Bates, Division of General Internal Medicine, 1620 Tremont St., Boston, MA 02115, United States of America, E-mail:
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7
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van Stiphout F, Zwart-van Rijkom JEF, Maggio LA, Aarts JECM, Bates DW, van Gelder T, Jansen PAF, Schraagen JMC, Egberts ACG, ter Braak EWMT. Task analysis of information technology-mediated medication management in outpatient care. Br J Clin Pharmacol 2015; 80:415-24. [PMID: 25753467 PMCID: PMC4574827 DOI: 10.1111/bcp.12625] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 03/01/2015] [Accepted: 03/03/2015] [Indexed: 11/29/2022] Open
Abstract
Aims Educating physicians in the procedural as well as cognitive skills of information technology (IT)-mediated medication management could be one of the missing links for the improvement of patient safety. We aimed to compose a framework of tasks that need to be addressed to optimize medication management in outpatient care. Methods Formal task analysis: decomposition of a complex task into a set of subtasks. First, we obtained a general description of the medication management process from exploratory interviews. Secondly, we interviewed experts in-depth to further define tasks and subtasks. Setting: Outpatient care in different fields of medicine in six teaching and academic medical centres in the Netherlands and the United States. Participants: 20 experts. Tasks were divided up into procedural, cognitive and macrocognitive tasks and categorized into the three components of dynamic decision making. Results The medication management process consists of three components: (i) reviewing the medication situation; (ii) composing a treatment plan; and (iii) accomplishing and communicating a treatment and surveillance plan. Subtasks include multiple cognitive tasks such as composing a list of current medications and evaluating the reliability of sources, and procedural tasks such as documenting current medication. The identified macrocognitive tasks were: planning, integration of IT in workflow, managing uncertainties and responsibilities, and problem detection. Conclusions All identified procedural, cognitive and macrocognitive skills should be included when designing education for IT-mediated medication management. The resulting framework supports the design of educational interventions to improve IT-mediated medication management in outpatient care.
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Affiliation(s)
- F van Stiphout
- Department of Internal Medicine & Centre for Research and Development of Education, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J E F Zwart-van Rijkom
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, the Netherlands.,Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - L A Maggio
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, CA, USA
| | - J E C M Aarts
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - D W Bates
- Division of General Internal Medicine, Brigham and Women's Hospital, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - T van Gelder
- Departments of Hospital Pharmacy and Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - P A F Jansen
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J M C Schraagen
- TNO Netherlands Organisation for Applied Scientific Research Earth, Life, and Social Sciences, Soesterberg, the Netherlands
| | - A C G Egberts
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, the Netherlands.,Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - E W M T ter Braak
- Department of Internal Medicine & Centre for Research and Development of Education, University Medical Centre Utrecht, Utrecht, the Netherlands
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Eliakim-Raz N, Bates DW, Leibovici L. Predicting bacteraemia in validated models--a systematic review. Clin Microbiol Infect 2015; 21:295-301. [PMID: 25677625 DOI: 10.1016/j.cmi.2015.01.023] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/21/2015] [Accepted: 01/22/2015] [Indexed: 11/18/2022]
Abstract
Bacteraemia is associated with high mortality. Although many models for predicting bacteraemia have been developed, not all have been validated, and even when they were, the validation processes varied. We identified validated models that have been developed; asked whether they were successful in defining groups with a very low or high prevalence of bacteraemia; and whether they were used in clinical practice. Electronic databases were searched to identify studies that underwent validation on prediction of bacteraemia in adults. We included only studies that were able to define groups with low or high probabilities for bacteraemia (arbitrarily defined as below 3% or above 30%). Fifteen publications fulfilled inclusion criteria, including 59 276 patients. Eleven were prospective and four retrospective. Study populations and the parameters included in the different models were heterogeneous. Ten studies underwent internal validation; the model performed well in all of them. Twelve performed external validation. Of the latter, seven models were validated in a different hospital, using a new independent database. In five of these, the model performed well. After contacting authors, we found that none of the models was implemented in clinical practice. We conclude that heterogeneous studies have been conducted in different defined groups of patients with limited external validation. Significant savings to the system and the individual patient can be gained by refraining from performing blood cultures in groups of patients in which the probability of true bacteraemia is very low, while the probability of contamination is constant. Clinical trials of existing or new models should be done to examine whether models are helpful and safe in clinical use, preferably multicentre in order to secure utility and safety in diverse clinical settings.
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Affiliation(s)
- N Eliakim-Raz
- Unit of Infectious Diseases Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
| | - D W Bates
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - L Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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Schiff GD, Amato MG, Eguale T, Boehne JJ, Wright A, Koppel R, Rashidee AH, Elson RB, Whitney DL, Thach TT, Bates DW, Seger AC. Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. BMJ Qual Saf 2015; 24:264-71. [PMID: 25595599 PMCID: PMC4392214 DOI: 10.1136/bmjqs-2014-003555] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
IMPORTANCE Medication computerised provider order entry (CPOE) has been shown to decrease errors and is being widely adopted. However, CPOE also has potential for introducing or contributing to errors. OBJECTIVES The objectives of this study are to (a) analyse medication error reports where CPOE was reported as a 'contributing cause' and (b) develop 'use cases' based on these reports to test vulnerability of current CPOE systems to these errors. METHODS A review of medication errors reported to United States Pharmacopeia MEDMARX reporting system was made, and a taxonomy was developed for CPOE-related errors. For each error we evaluated what went wrong and why and identified potential prevention strategies and recurring error scenarios. These scenarios were then used to test vulnerability of leading CPOE systems, asking typical users to enter these erroneous orders to assess the degree to which these problematic orders could be entered. RESULTS Between 2003 and 2010, 1.04 million medication errors were reported to MEDMARX, of which 63 040 were reported as CPOE related. A review of 10 060 CPOE-related cases was used to derive 101 codes describing what went wrong, 67 codes describing reasons why errors occurred, 73 codes describing potential prevention strategies and 21 codes describing recurring error scenarios. Ability to enter these erroneous order scenarios was tested on 13 CPOE systems at 16 sites. Overall, 298 (79.5%) of the erroneous orders were able to be entered including 100 (28.0%) being 'easily' placed, another 101 (28.3%) with only minor workarounds and no warnings. CONCLUSIONS AND RELEVANCE Medication error reports provide valuable information for understanding CPOE-related errors. Reports were useful for developing taxonomy and identifying recurring errors to which current CPOE systems are vulnerable. Enhanced monitoring, reporting and testing of CPOE systems are important to improve CPOE safety.
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Affiliation(s)
- G D Schiff
- Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA Harvard School of Medicine, Boston, Massachusetts, USA
| | - M G Amato
- Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA MCPHS University, Boston, Massachusetts, USA
| | - T Eguale
- Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA Harvard School of Medicine, Boston, Massachusetts, USA McGill University, Montreal, Quebec, Canada
| | - J J Boehne
- Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA
| | - A Wright
- Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA Harvard School of Medicine, Boston, Massachusetts, USA
| | - R Koppel
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - R B Elson
- MetroHealth Center for HealthCare Research and Policy, Cleveland, Ohio, USA
| | - D L Whitney
- Baylor College of Medicine, Houston, Texas, USA
| | - T-T Thach
- Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA
| | - D W Bates
- Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA Harvard School of Medicine, Boston, Massachusetts, USA Harvard School of Public Health, Boston, Massachusetts, USA
| | - A C Seger
- Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA MCPHS University, Boston, Massachusetts, USA
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Wright A, Feblowitz J, Maloney FL, Henkin S, Ramelson H, Feltman J, Bates DW. Increasing patient engagement: patients' responses to viewing problem lists online. Appl Clin Inform 2014; 5:930-42. [PMID: 25589908 DOI: 10.4338/aci-2014-07-ra-0057] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 11/01/2014] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To characterize the opinions, emotions, and actions taken by patients who viewed their electronic problem list via an online personal health record (PHR). MATERIALS AND METHODS An online survey of patients who viewed their problem lists, as maintained by their healthcare provider, in a web-based PHR linked to an electronic health record for the first time. RESULTS A total 3,649 patients completed the survey, yielding a response rate of 42.1%. Patient attitudes towards the problem list function were positive overall, with 90.4% rating it at least somewhat useful and 86.7% reporting they would probably or definitely use it again. Nearly half (45.6%) of patients identified at least one major or minor problem missing from their list. After viewing the list, 56.1% of patients reported taking at least one action in response, with 32.4% of patients reporting that they researched a condition on the Internet, 18.3% reported that they contacted their healthcare provider and 16.7% reported changing or planning to change a health behavior (patients could report multiple actions). 64.7% of patients reported feeling at least somewhat happy while viewing their problem list, though others reported feeling sad (30.4%), worried (35.7%) or scared (23.8%) (patients could report multiple emotions). A smaller number of patients reported feeling angry (16.6%) or ashamed (14.3%). Patients who experienced an emotional response were more likely to take action. CONCLUSION Overall, patients found the ability to view their problem lists very useful and took action in response to the information. However, some had negative emotions. More research is needed into optimal strategies for supporting patients receiving this information.
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Affiliation(s)
- A Wright
- Division of General Internal Medicine, Brigham & Women's Hospital , Boston, MA ; Partners HealthCare , Boston, MA ; Harvard Medical School , Boston, MA
| | - J Feblowitz
- Division of General Internal Medicine, Brigham & Women's Hospital , Boston, MA ; Partners HealthCare , Boston, MA ; Harvard Medical School , Boston, MA
| | | | - S Henkin
- Division of General Internal Medicine, Brigham & Women's Hospital , Boston, MA ; Partners HealthCare , Boston, MA
| | - H Ramelson
- Division of General Internal Medicine, Brigham & Women's Hospital , Boston, MA ; Partners HealthCare , Boston, MA ; Harvard Medical School , Boston, MA
| | | | - D W Bates
- Division of General Internal Medicine, Brigham & Women's Hospital , Boston, MA ; Partners HealthCare , Boston, MA ; Harvard Medical School , Boston, MA ; Harvard School of Public Health , Boston, MA
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Ohta Y, Sakuma M, Koike K, Bates DW, Morimoto T. Influence of adverse drug events on morbidity and mortality in intensive care units: the JADE study. Int J Qual Health Care 2014; 26:573-8. [DOI: 10.1093/intqhc/mzu081] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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12
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Emani S, Ting DY, Healey M, Lipsitz SR, Karson AS, Einbinder JS, Leinen L, Suric V, Bates DW. Physician beliefs about the impact of meaningful use of the EHR: a cross-sectional study. Appl Clin Inform 2014; 5:789-801. [PMID: 25298817 DOI: 10.4338/aci-2014-05-ra-0050] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 07/18/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND As adoption and use of electronic health records (EHRs) grows in the United States, there is a growing need in the field of applied clinical informatics to evaluate physician perceptions and beliefs about the impact of EHRs. The meaningful use of EHR incentive program provides a suitable context to examine physician beliefs about the impact of EHRs. OBJECTIVE Contribute to the sparse literature on physician beliefs about the impact of EHRs in areas such as quality of care, effectiveness of care, and delivery of care. METHODS A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who were preparing to qualify for the meaningful use of EHR incentive program. RESULTS Of the 1,797 physicians at both AMCs who were preparing to qualify for the incentive program, 967 completed the survey for an overall response rate of 54%. Only 23% and 27% of physicians agreed or strongly agreed that meaningful use of the EHR will help them improve the care they personally deliver and improve quality of care respectively. Physician specialty was significantly associated with beliefs; e.g., 35% of primary care physicians agreed or strongly agreed that meaningful use will improve quality of care compared to 26% of medical specialists and 21% of surgical specialists (p=0.009). Satisfaction with outpatient EHR was also significantly related to all belief items. CONCLUSIONS Only about a quarter of physicians in our study responded positively that meaningful use of the EHR will improve quality of care and the care they personally provide. These findings are similar to and extend findings from qualitative studies about negative perceptions that physicians hold about the impact of EHRs. Factors outside of the regulatory context, such as physician beliefs, need to be considered in the implementation of the meaningful use of the EHR incentive program.
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Affiliation(s)
- S Emani
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA
| | - D Y Ting
- Massachusetts General Physicians Organization, Massachusetts General Hospital , Boston, MA, USA
| | - M Healey
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA ; Brigham and Women's Physicians Organization, Brigham and Women's Hospital , Boston, MA, USA
| | - S R Lipsitz
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA
| | - A S Karson
- Decision Support Unit, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
| | - J S Einbinder
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA
| | - L Leinen
- Information Services, Partners HealthCare , Boston, MA, USA
| | - V Suric
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA
| | - D W Bates
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA ; Department of Healthcare Policy and Management, Harvard School of Public Health , Boston, MA, USA
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Cho I, Lee J, Han H, Phansalkar S, Bates DW. Evaluation of a Korean version of a tool for assessing the incorporation of human factors into a medication-related decision support system: the I-MeDeSA. Appl Clin Inform 2014; 5:571-88. [PMID: 25024770 DOI: 10.4338/aci-2014-01-ra-0005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 05/07/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The Instrument for Evaluating Human-Factor Principles in Medication-Related Decision Support Alerts (I-MeDeSA) was developed recently in the US with a view towards improving considerations of human-factor principles when designing alerts for clinical decision support (CDS) systems. This study evaluated the generalizability of this tool, in cooperation with its authors, across cultures by applying it to a Korean system. We also examined opportunities to promote user acceptance of the system. METHODS We developed a Korean version of the I-MeDeSA (K-I-MeDeSA) and used it to evaluate drug-drug interaction alerts in a large academic tertiary hospital in Seoul. We involved four reviewers (A, B, C, and D). Two (A and B) conducted the initial independent scoring, while the other two (C and D) performed a final review and assessed feedback from the initial reviewers. The obtained scores were compared with those from 13 previously reported CDS systems. The feedback was summarized qualitatively. RESULTS The translation of the I-MeDeSA had excellent interrater agreement in terms of face validity (scale-level content validity index = 0.95). The system's K-I-MeDeSA score was 10 out of 26, with a good agreement between reviewers (κ = 0.77), which showed a lack of human-factor considerations. The reviewers readily identified two of the nine principles that needed primary improvement: prioritization and text-based information. The reviewers also expressed difficulty judging the following four principles: alarm philosophy, visibility, color, and learnability and confusability. CONCLUSION The K-I-MeDeSA was semantically and operationally equivalent to the original tool. Only minor cultural problems were identified, leading the reviewers to suggest the need for clarification of certain words plus a more detailed description of the tool's rationale and exemplars. Further evaluation is needed to empirically assess whether the implementation of changes in an electronic health record system could improve the adoption of CDS alerts.
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Affiliation(s)
- I Cho
- Department of Nursing, School of Medicine, Inha University , Incheon, Korea ; Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA, USA ; Harvard Medical School , Boston, MA, USA
| | - J Lee
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA, USA ; Harvard Medical School , Boston, MA, USA ; Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center , Seoul, Korea ; Department of Biomedical Informatics, Asan Medical Center , Seoul, Korea
| | - H Han
- Department of Pharmacy, Asan Medical Center , Seoul, Korea
| | - S Phansalkar
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA, USA ; Harvard Medical School , Boston, MA, USA ; Partners Healthcare Systems , Wellesley, MA, USA ; Wolters Kluwer Health , Indianapolis, IN, USA
| | - D W Bates
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA, USA ; Harvard Medical School , Boston, MA, USA ; Partners Healthcare Systems , Wellesley, MA, USA
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Neri PM, Volk LA, Samaha S, Pollard SE, Williams DH, Fiskio JM, Burdick E, Edwards ST, Ramelson H, Schiff GD, Bates DW. Relationship between documentation method and quality of chronic disease visit notes. Appl Clin Inform 2014; 5:480-90. [PMID: 25024762 DOI: 10.4338/aci-2014-01-ra-0007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/15/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assses the relationship between methods of documenting visit notes and note quality for primary care providers (PCPs) and specialists, and to determine the factors that contribute to higher quality notes for two chronic diseases. METHODS Retrospective chart review of visit notes at two academic medical centers. Two physicians rated the subjective quality of content areas of the note (vital signs, medications, lifestyle, labs, symptoms, assessment & plan), overall quality, and completed the 9 item Physician Documentation Quality Instrument (PDQI-9). We evaluated quality ratings in relation to the primary method of documentation (templates, free-form or dictation) for both PCPs and specialists. A one factor analysis of variance test was used to examine differences in mean quality scores among the methods. RESULTS A total of 112 physicians, 71 primary care physicians (PCP) and 41 specialists, wrote 240 notes. For specialists, templated notes had the highest overall quality scores (p≤0.001) while for PCPs, there was no statistically significant difference in overall quality score. For PCPs, free form received higher quality ratings on vital signs (p = 0.01), labs (p = 0.002), and lifestyle (p = 0.002) than other methods; templated notes had a higher rating on medications (p≤0.001). For specialists, templated notes received higher ratings on vital signs, labs, lifestyle and medications (p = 0.001). DISCUSSION There was no significant difference in subjective quality of visit notes written using free-form documentation, dictation or templates for PCPs. The subjective quality rating of templated notes was higher than that of dictated notes for specialists. CONCLUSION As there is wide variation in physician documentation methods, and no significant difference in note quality between methods, recommending one approach for all physicians may not deliver optimal results.
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Affiliation(s)
- P M Neri
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - L A Volk
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - S Samaha
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - S E Pollard
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - D H Williams
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA
| | - J M Fiskio
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - E Burdick
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA
| | - S T Edwards
- Harvard Medical School , Boston, MA ; Massachusetts Veteran's Epidemiology Research and Information Center, Veteran's Affairs Boston Healthcare System , Boston, MA ; Section of General Internal Medicine, Veteran's Affairs Boston Healthcare System , Boston, MA
| | - H Ramelson
- Information Systems, Partners Healthcare System , Wellesley, MA ; Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA ; Harvard Medical School , Boston, MA
| | - G D Schiff
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA ; Harvard Medical School , Boston, MA
| | - D W Bates
- Information Systems, Partners Healthcare System , Wellesley, MA ; Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA ; Harvard Medical School , Boston, MA
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Wells S, Rozenblum R, Park A, Dunn M, Bates DW. Personal health records for patients with chronic disease: a major opportunity. Appl Clin Inform 2014; 5:416-29. [PMID: 25024758 DOI: 10.4338/aci-2014-01-ra-0002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/05/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Personal health records (PHRs) connected to a physician's electronic health record system hold substantial promise for supporting and engaging patients with chronic disease. OBJECTIVES To explore how U.S. health care organizations are currently utilizing PHRs for chronic disease populations. METHODS A mixed methods study including semi-structured interviews and a questionnaire was conducted. A purposive sample was developed of health care organizations which were recognized as exemplars for PHRs and were high performers in national patient satisfaction surveys (H-CAHPS or CAHPS). Within each organization, participants were health IT leaders or those managing high-risk or chronic disease populations. RESULTS Interviews were conducted with 30 informants and completed questionnaires were received from 16 organizations (84% response rate). Most PHRs allowed patients to access health records and educational material, message their provider, renew prescriptions and request appointments. Patient generated data was increasingly being sought and combined with messaging, resulted in greater understanding of patient health and functioning outside of the clinic visit. However for chronic disease populations, there was little targeted involvement in PHR design and few tools to help interpret and manage their conditions beyond those offered for all. The PHR was largely uncoupled from high risk population management interventions and no clear framework for future PHR development emerged. CONCLUSION This technology is currently underutilized and represents a major opportunity given the potential benefits of patient engagement and shared decision making. A coherent patient-centric PHR design and evaluation strategy is required to realize its potential and maximize this natural hub for multidisciplinary care co-ordination.
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Affiliation(s)
- S Wells
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland , Auckland, New Zealand ; Department of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, Massachusetts
| | - R Rozenblum
- Department of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, Massachusetts
| | - A Park
- Department of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, Massachusetts
| | - M Dunn
- Department of Health Care Policy and Management, Harvard School of Public Health , Boston, Massachusetts
| | - D W Bates
- Department of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, Massachusetts ; Department of Health Care Policy and Management, Harvard School of Public Health , Boston, Massachusetts
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Aljadhey H, Mahmoud MA, Mayet A, Alshaikh M, Ahmed Y, Murray MD, Bates DW. Incidence of adverse drug events in an academic hospital: a prospective cohort study. Int J Qual Health Care 2013; 25:648-55. [DOI: 10.1093/intqhc/mzt075] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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17
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Newsham D, Bates DW, Borycki EM. eHealth in North America. Yearb Med Inform 2013. [DOI: 10.1055/s-0038-1638839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Summary
Objective: The overall objective of this paper is to provide an overview of the current status of electronic health record (EHR) adoption and implementation in Canada and the United States.
Methods: A review and synthesis of the empirical and grey literature about adoption of electronic health records in Canada and the United States was undertaken.
Results: Both Canada and the United States have experienced increases in their adoption rates. More specifically, 2012 adoption statistics reveal that the electronic medical record adoption rate in the United States is 69% and in Canada it is 57%. Significant investment by both governments has increased adoption of electronic records across North America.
Conclusions: In the United States and Canada there has been a significant rise in the adoption of electronic records by health professionals with the aid of national government incentive programs.
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Feblowitz J, Henkin S, Pang J, Ramelson H, Schneider L, Maloney FL, Wilcox AR, Bates DW, Wright A. Provider use of and attitudes towards an active clinical alert: a case study in decision support. Appl Clin Inform 2013; 4:144-52. [PMID: 23650494 DOI: 10.4338/aci-2012-12-ra-0055] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 03/12/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In a previous study, we reported on a successful clinical decision support (CDS) intervention designed to improve electronic problem list accuracy, but did not study variability of provider response to the intervention or provider attitudes towards it. The alert system accurately predicted missing problem list items based on health data captured in a patient's electronic medical record. OBJECTIVE To assess provider attitudes towards a rule-based CDS alert system as well as heterogeneity of acceptance rates across providers. METHODS We conducted a by-provider analysis of alert logs from the previous study. In addition, we assessed provider opinions of the intervention via an email survey of providers who received the alerts (n = 140). RESULTS Although the alert acceptance rate was 38.1%, individual provider acceptance rates varied widely, with an interquartile range (IQR) of 14.8%-54.4%, and many outliers accepting none or nearly all of the alerts they received. No demographic variables, including degree, gender, age, assigned clinic, medical school or graduation year predicted acceptance rates. Providers' self-reported acceptance rate and perceived alert frequency were only moderately correlated with actual acceptance rates and alert frequency. CONCLUSIONS Acceptance of this CDS intervention among providers was highly variable but this heterogeneity is not explained by measured demographic factors, suggesting that alert acceptance is a complex and individual phenomenon. Furthermore, providers' self-reports of their use of the CDS alerting system correlated only modestly with logged usage.
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19
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Bates DW, Baysari MT, Dugas M, Haefeli WE, Kushniruk AW, Lehmann CU, Liu J, Mantas J, Margolis A, Miyo K, Nohr C, Peleg M, de Quirós FGB, Slight SP, Starmer J, Takabayashi K, Westbrook JI. Discussion of "Attitude of physicians towards automatic alerting in computerized physician order entry systems". Methods Inf Med 2013; 52:109-127. [PMID: 23508343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
With these comments on the paper "Attitude of Physicians Towards Automatic Alerting in Computerized Physician Order Entry Systems", written by Martin Jung and co-authors, with Dr. Elske Ammenwerth as senior author [1], the journal wants to stimulate a broad discussion on computerized physician order entry systems. An international group of experts have been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.
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Affiliation(s)
- D W Bates
- Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts 02120, USA.
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20
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Borycki EM, Newsham D, Bates DW. eHealth in North America. Yearb Med Inform 2013; 8:103-106. [PMID: 23974555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE The overall objective of this paper is to provide an overview of the current status of electronic health record (EHR) adoption and implementation in Canada and the United States. METHODS A review and synthesis of the empirical and grey literature about adoption of electronic health records in Canada and the United States was undertaken. RESULTS Both Canada and the United States have experienced increases in their adoption rates. More specifically, 2012 adoption statistics reveal that the electronic medical record adoption rate in the United States is 69% and in Canada it is 57%. Significant investment by both governments has increased adoption of electronic records across North America. CONCLUSIONS In the United States and Canada there has been a significant rise in the adoption of electronic records by health professionals with the aid of national government incentive programs.
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Affiliation(s)
- E M Borycki
- School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada. E-mail:
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21
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Abstract
BACKGROUND Unsafe medical care may cause substantial morbidity and mortality globally, despite imprecise estimates of the magnitude of the problem. To better understand the extent and nature of the problem of unsafe care, the WHO World Alliance for Patient Safety commissioned an overview of the world's literature on patient safety research. METHODS Major patient safety topics were identified through a consultative and investigative process and were categorised into the framework of structure, process and outcomes of unsafe care. Lead experts examined current evidence and identified major knowledge gaps relating to topics in developing, transitional and developed nations. The report was reviewed by internal and external experts and underwent improvements based on the feedback. FINDINGS Twenty-three major patient safety topics were examined. Much of the evidence of the outcomes of unsafe care is from developed nations, where prevalence studies demonstrate that between 3% and 16% of hospitalised patients suffer harm from medical care. Data from transitional and developing countries also suggest substantial harm from medical care. However, considerable gaps in knowledge about the structural and process factors that underlie unsafe care globally make solutions difficult to identify, especially in resource-poor settings. INTERPRETATION Harm from medical care appears to pose a substantial burden to the world's population. However, much of the evidence base comes from developed nations. Understanding the scope of and solutions for unsafe care for the rest of the world is a critical component of delivering safe, effective care to all of the world's citizens.
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Affiliation(s)
- A K Jha
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA.
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22
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Bates DW, Edmunds M. AMIA policy activities. J Am Med Inform Assoc 2012. [DOI: 10.1136/amiajnl-2012-000813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Adler RA, Bates DW, Dell RM, LeBoff MS, Majumdar SR, Saag KG, Solomon DH, Suarez-Almazor ME. Systems-based approaches to osteoporosis and fracture care: policy and research recommendations from the workgroups. Osteoporos Int 2011; 22 Suppl 3:495-500. [PMID: 21847772 DOI: 10.1007/s00198-011-1708-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 06/22/2011] [Indexed: 10/17/2022]
Abstract
Participants in the conference selected to attend two different working group sessions. The working groups discussed different perspectives of system-based approaches to osteoporosis and fracture care. The group on postfracture case management recommended that nurse case managers be used to improve communication among patients, orthopaedic surgeons, and those providing ongoing clinical care. The hospital working group discussed the impact of and barriers to improved postfracture management in the hospital setting. The health systems group emphasized the difference between a closed system in which long-term benefits of interventions were more likely to be appreciated than in fee for service systems. The health information technology group discussed the advantages and challenges of electronic health records. The working group on consumer and provider education discussed interventions for both primary and secondary prevention of fractures. Recommendations were produced by most groups for improving postfracture care.
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Affiliation(s)
- R A Adler
- Endocrinology Section, McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
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24
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Aranaz-Andrés JM, Aibar-Remón C, Limón-Ramírez R, Amarilla A, Restrepo FR, Urroz O, Sarabia O, García-Corcuera LV, Terol-García E, Agra-Varela Y, Gonseth-García J, Bates DW, Larizgoitia I. Prevalence of adverse events in the hospitals of five Latin American countries: results of the 'Iberoamerican Study of Adverse Events' (IBEAS). BMJ Qual Saf 2011; 20:1043-51. [PMID: 21712370 DOI: 10.1136/bmjqs.2011.051284] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Interest in patient safety (PS) is growing exponentially, fuelled by epidemiological research unveiling the extent of unsafe care. However, there is little information about the frequency of harm in developing and transitional countries. To address this issue, the authors performed a study known as the Iberoamerican Adverse Event Study, through a collaborative between the governments of Argentina, Colombia, Costa Rica, Mexico and Peru, the Spanish Ministry of Health, Social Policy and Equality, the Pan American Health Organization and the WHO Patient Safety. METHODS The study used a cross-sectional design, involving 58 hospitals in the five Latin American countries, to measure the point prevalence of patients presenting an adverse event (AE) on the day of observation. All inpatients at the time of the study were included. RESULTS A total of 11 379 inpatients were surveyed. Of these, 1191 had at least one AE that the reviewer judged to be related to the care received rather than to the underlying conditions. The estimated point prevalence rate was 10.5% (95% CI 9.91 to 11.04), with more than 28% of AE causing disability and another 6% associated with the death of the patient. Almost 60% of AE were considered preventable. CONCLUSIONS The high rate of prevalent AE found suggests that PS may represent an important public-health issue in the participating hospitals. While new studies may be needed to confirm these results, these may already be useful to inspire new PS-improvement policies in those settings.
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Affiliation(s)
- J M Aranaz-Andrés
- Department of Public Health, Universidad Miguel Hernández, Campus de San Juan, Carretera Alicante-Valencia Km 87, 03550 San Juan de Alicante.
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Phansalkar S, Wright A, Kuperman GJ, Vaida AJ, Bobb AM, Jenders RA, Payne TH, Halamka J, Bloomrosen M, Bates DW. Towards meaningful medication-related clinical decision support: recommendations for an initial implementation. Appl Clin Inform 2011; 2:50-62. [PMID: 23616860 DOI: 10.4338/aci-2010-04-ra-0026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 01/24/2011] [Indexed: 11/23/2022] Open
Abstract
SUMMARY Clinical decision support (CDS) can improve safety, quality, and cost-effectiveness of patient care, especially when implemented in computerized provider order entry (CPOE) applications. Medication-related decision support logic forms a large component of the CDS logic in any CPOE system. However, organizations wishing to implement CDS must either purchase the computable clinical content or develop it themselves. Content provided by vendors does not always meet local expectations. Most organizations lack the resources to customize the clinical content and the expertise to implement it effectively. In this paper, we describe the recommendations of a national expert panel on two basic medication-related CDS areas, specifically, drug-drug interaction (DDI) checking and duplicate therapy checking. The goals of this study were to define a starter set of medication-related alerts that healthcare organizations can implement in their clinical information systems. We also draw on the experiences of diverse institutions to highlight the realities of implementing medication decision support. These findings represent the experiences of institutions with a long history in the domain of medication decision support, and the hope is that this guidance may improve the feasibility and efficiency CDS adoption across healthcare settings.
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Kaushal R, Goldmann DA, Keohane CA, Abramson EL, Woolf S, Yoon C, Zigmont K, Bates DW. Medication errors in paediatric outpatients. BMJ Qual Saf 2010; 19:e30. [DOI: 10.1136/qshc.2008.031179] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Carpenter KB, Duevel MA, Lee PW, Wu AW, Bates DW, Runciman WB, Baker GR, Larizgoitia I, Weeks WB. Measures of patient safety in developing and emerging countries: a review of the literature. Qual Saf Health Care 2010; 19:48-54. [DOI: 10.1136/qshc.2008.031088] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hug BL, Lipsitz SR, Seger DL, Karson AS, Wright SC, Bates DW. Mortality and drug exposure in a 5-year cohort of patients with chronic liver disease. Swiss Med Wkly 2009; 139:737-46. [PMID: 19924579 DOI: 10.4414/smw.2009.12686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Chronic liver diseases are common in the general population. Drug treatment in this group may be challenging, as many drugs are hepatically metabolised and hepatotoxic. OBJECTIVES We aimed to assess the mortality of patients with chronic liver disease according to specific drug exposures and the three laboratory parameters creatinine, bilirubin and International Normalised Ratio (INR). METHODS We conducted a multicentre, 5-year retrospective cohort study in two tertiary university referral hospitals and a secondary referral hospital, using a research database to evaluate the crude and adjusted mortality. RESULTS Of 1159362 individual patients 1.7% (n = 20158) had chronic liver disease and in this group 36.8% had unspecified chronic non-alcoholic liver disease, 30.1% chronic hepatitis C and 11.9% cirrhosis of the liver. 8.4% of patients presented a diagnosis associated with alcohol. The 4-year survival rates were significantly higher in the group with the most normal laboratory values (94.3%) versus 34.5% in the group with elevated parameters (p <0.001). Overall, drug exposure was not associated with higher mortality; in adjusted multivariate analysis the hazard ratio for anti-cancer drugs was 2.69 (95% CI 1.32-5.46). Of individual drugs, mortality hazard ratios for amiodarone, morphine oral, acetazolamide, sirolimus and lamivudine were 2.46 (95% CI 1.68-3.61), 2.26 (95% CI 1.78-2.86), 2.10 (95% CI 1.19-3.70), 1.81 (95% CI 1.02-3.21) and 1.72 (95% CI 1.17-2.53) respectively. CONCLUSIONS Drug exposure in general was not associated with higher mortality except for a few categories. Mortality in patients with chronic liver disease was high and is associated with simple laboratory values.
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Affiliation(s)
- B L Hug
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Bates DW, Einbinder JS. Section 1: Health and Clinical Management: Leveraging Information Technology to Improve Quality and Safety. Yearb Med Inform 2007. [DOI: 10.1055/s-0038-1638515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
SummaryTo examine five areas that we will be central to informatics research in the years to come: changing provider behavior and improving outcomes, secondary uses of clinical data, using health information technology to improve patient safety, personal health records, and clinical data exchange.Potential articles were identified through Medline and Internet searches and were selected for inclusion in this review by the authors.We review highlights from the literature in these areas over the past year, drawing attention to key points and opportunities for future work.Informatics may be a key tool for helping to improve patient care quality, safety, and efficiency. However, questions remain about how best to use existing technologies, deploy new ones, and to evaluate the effects. A great deal of research has been done on changing provider behavior, but most work to date has shown that process benefits are easier to achieve than outcomes benefits, especially for chronic diseases. Use of secondary data (data warehouses and disease registries) has enormous potential, though published research is scarce. It is now clear in most nations that one of the key tools for improving patient safety will be information technology— many more studies of different approaches are needed in this area. Finally, both personal health records and clinical data exchange appear to be potentially transformative developments, but much of the published research to date on these topics appears to be taking place in the U.S.— more research from other nations is needed.
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Einbinder JS, Bates DW. Leveraging information technology to improve quality and safety. Yearb Med Inform 2007:22-9. [PMID: 17700900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES To examine five areas that we will be central to informatics research in the years to come: changing provider behavior and improving outcomes, secondary uses of clinical data, using health information technology to improve patient safety, personal health records, and clinical data exchange. METHODS Potential articles were identified through Medline and Internet searches and were selected for inclusion in this review by the authors. RESULTS We review highlights from the literature in these areas over the past year, drawing attention to key points and opportunities for future work. CONCLUSIONS Informatics may be a key tool for helping to improve patient care quality, safety, and efficiency. However, questions remain about how best to use existing technologies, deploy new ones, and to evaluate the effects. A great deal of research has been done on changing provider behavior, but most work to date has shown that process benefits are easier to achieve than outcomes benefits, especially for chronic diseases. Use of secondary data (data warehouses and disease registries) has enormous potential, though published research is scarce. It is now clear in most nations that one of the key tools for improving patient safety will be information technology--many more studies of different approaches are needed in this area. Finally, both personal health records and clinical data exchange appear to be potentially transformative developments, but much of the published research to date on these topics appears to be taking place in the U.S.--more research from other nations is needed.
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Affiliation(s)
- J S Einbinder
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Leape LL, Rogers G, Hanna D, Griswold P, Federico F, Fenn CA, Bates DW, Kirle L, Clarridge BR. Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. Qual Saf Health Care 2006; 15:289-95. [PMID: 16885255 PMCID: PMC2564013 DOI: 10.1136/qshc.2005.017632] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2006] [Indexed: 11/04/2022]
Abstract
BACKGROUND Disseminating new safe practices has proved challenging. In a statewide initiative we developed a framework for (1) selecting two safe practices, (2) developing operational details of implementation, (3) enlisting hospitals to participate, and (4) facilitating implementation. METHODS Potential topics were selected by a multistep process to identify candidate practices, review the evidence for efficacy and feasibility, and then select them on the basis of importance, efficacy, feasibility, and impact. A multi-stakeholder advisory group representing all constituencies selected two practices: reconciling medications (RM) and communicating critical test results (CTR). Operational details and strategies for implementation were then developed for each practice using a consensus process of discipline stakeholders led by content experts. Hospital CEOs were solicited to participate by the Massachusetts Hospital Association which made the project a "flagship" initiative. A collaborative model was used to facilitate implementation, following the IHI Model for Improvement. In addition to providing exposure to content and method experts, we gave teams a "toolkit" containing recommendations, a change package, and implementation strategies. Each collaborative met four times over an 18 month period. Results were assessed using the IHI team assessment scale and surveys of teams and hospital leaders. RESULTS Hospital participation rate was high with 88% of hospitals participating in one or both collaboratives. Partial implementation of the practices was achieved by 50% of RM teams and 65% of CTR teams. Full implementation was achieved by 20% of teams for each. CONCLUSIONS Major factors leading to hospital participation included the intrinsic appeal of the practices, access to experts, and the availability of implementation strategies. Team success was correlated with active engagement of a senior administrator, engagement of physicians, increased use of PDSA cycles, and attendance at collaborative meetings. The prior development of subpractices, recommendations and implementation strategies was essential for the hospital teams. These should be well worked out before hospitals are required to implement any guideline.
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Affiliation(s)
- L L Leape
- Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
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Abstract
BACKGROUND AND OBJECTIVE Antiviral medications cost-effectively reduce influenza-related morbidity and potentially mortality. We sought to assess the appropriateness of antiviral prescribing for influenza. METHOD We performed a retrospective analysis of visits by adults to primary care clinics during influenza seasons from 1 October 2000 to 31 May 2004 with a claims diagnosis of influenza (n=535) or with an electronic antiviral prescription (n=25). We defined appropriate antiviral prescribing as the patient having (a) symptoms for 2 or fewer days, (b) fever and (c) any two of headache, sore throat, cough, or myalgias. RESULTS AND DISCUSSION Physicians diagnosed patients with influenza in 102 of 535 (19%) visits with a claims diagnosis of influenza. Physicians prescribed antivirals at 15 of 102 (15%) of these visits. The addition of 25 additional electronic antiviral prescriptions gave a sample of 127 visits and 40 (31%) antiviral prescriptions. Twenty-eight (70%) antiviral prescriptions were appropriate. Among patients who did not receive antivirals, 21 of 87 (24%) met criteria for appropriate antiviral prescribing. Antiviral prescribing was associated with a shorter median symptom duration (2 days vs. 3 days; P<0.01) and higher median temperature (37.8 degrees C vs. 36.9 degrees C; P<0.01). Physicians prescribed antivirals more frequently to patients who had myalgias (37% vs. 18%; P=0.04) and an influenza test (67% vs. 28%; P<0.01). Physicians prescribed antivirals more frequently to Blacks (44%) and patients with other race/ethnicity (67%) than to Whites (20%) or Hispanics (20%; P<0.0001). CONCLUSIONS To improve antiviral prescribing for influenza in primary care, interventions need to target the accurate identification of influenza visits, undertreatment, as well as inappropriate treatment.
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Affiliation(s)
- J A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA 02120, USA.
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Abstract
BACKGROUND The "To Err is Human" report published by the Institute of Medicine (IOM) in 1999 called for a national effort to make health care safer. Although the report has been widely credited with spawning efforts to study and improve safety in health care, there has been limited objective assessment of its impact. We evaluated the effects of the IOM report on patient safety publications and research awards. METHODS We searched MEDLINE to identify English language articles on patient safety and medical errors published between 1 November 1994 and 1 November 2004. Using interrupted time series analyses, changes in the number, type, and subject matter of patient safety publications were measured. We also examined federal (US only) funding of patient safety research awards for the fiscal years 1995-2004. RESULTS A total of 5514 articles on patient safety and medical errors were published during the 10 year study period. The rate of patient safety publications increased from 59 to 164 articles per 100,000 MEDLINE publications (p<0.001) following the release of the IOM report. Increased rates of publication were observed for all types of patient safety articles. Publications of original research increased from an average of 24 to 41 articles per 100,000 MEDLINE publications after the release of the report (p<0.001), while patient safety research awards increased from 5 to 141 awards per 100,000 federally funded biomedical research awards (p<0.001). The most frequent subject of patient safety publications before the IOM report was malpractice (6% v 2%, p<0.001) while organizational culture was the most frequent subject (1% v 5%, p<0.001) after publication of the report. CONCLUSIONS Publication of the report "To Err is Human" was associated with an increased number of patient safety publications and research awards. The report appears to have stimulated research and discussion about patient safety issues, but whether this will translate into safer patient care remains unknown.
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Affiliation(s)
- H T Stelfox
- Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Ammenwerth E, Talmon J, Ash JS, Bates DW, Beuscart-Zéphir MC, Duhamel A, Elkin PL, Gardner RM, Geissbuhler A. Impact of CPOE on mortality rates--contradictory findings, important messages. Methods Inf Med 2006; 45:586-93. [PMID: 17149499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To analyze the seemingly contradictory results of the Han study (Pediatrics 2005) and the Del Beccaro study (Pediatrics 2006), both analyzing the effect of CPOE systems on mortality rates in pediatric intensive care settings. METHODS Seven CPOE system experts from the United States and Europe comment on these papers. RESULTS The two studies are not contradictory, but almost non-comparable due to differences in design and implementation. They demonstrate the range of outcomes that can be obtained from introducing informatics applications in complex health care settings. Implementing informatics applications is a sociotechnical activity, which often depends more on the organizational context than on a specific technology. As health informaticians, we must not only learn from failures, but also avoid both uncritical scepticism that may arise from drawing overly general conclusions from one negative trial, as much as uncritical optimism from limited successful ones. CONCLUSION The commentaries emphasize the need to promote systematic studies for assessing the socio-technical factors that influence the introduction of increasingly sophisticated informatics applications within complex organizations. The emergence of evidence-based health informatics will be based both on evaluation guidelines and implementation guidelines, both of which increase the chances of successful implementation. In addition, well-educated health informaticians are needed to manage and guide the implementation processes.
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Affiliation(s)
- E Ammenwerth
- University for Health Sciences, Medical Informatics and Technology, Institute for Health Information Systems, Eduard-Wallnöfer-Zentrum I, 6060 Hall, Tyrol, Austria.
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Abstract
Investigating the incidence, type, and preventability of adverse drug events (ADEs) and medication errors is crucial to improving the quality of health care delivery. ADEs, potential ADEs, and medication errors can be collected by extraction from practice data, solicitation of incidents from health professionals, and patient surveys. Practice data include charts, laboratory, prescription data, and administrative databases, and can be reviewed manually or screened by computer systems to identify signals. Research nurses, pharmacists, or research assistants review these signals, and those that are likely to represent an ADE or medication error are presented to reviewers who independently categorize them into ADEs, potential ADEs, medication errors, or exclusions. These incidents are also classified according to preventability, ameliorability, disability, severity, stage, and responsible person. These classifications, as well as the initial selection of incidents, have been evaluated for agreement between reviewers and the level of agreement found ranged from satisfactory to excellent (kappa = 0.32-0.98). The method of ADE and medication error detection and classification described is feasible and has good reliability. It can be used in various clinical settings to measure and improve medication safety.
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Affiliation(s)
- T Morimoto
- Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120-1613, USA
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Morimoto T, Gandhi TK, Seger AC, Hsieh TC, Bates DW. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care 2004; 13:306-14. [PMID: 15289635 PMCID: PMC1743868 DOI: 10.1136/qhc.13.4.306] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Investigating the incidence, type, and preventability of adverse drug events (ADEs) and medication errors is crucial to improving the quality of health care delivery. ADEs, potential ADEs, and medication errors can be collected by extraction from practice data, solicitation of incidents from health professionals, and patient surveys. Practice data include charts, laboratory, prescription data, and administrative databases, and can be reviewed manually or screened by computer systems to identify signals. Research nurses, pharmacists, or research assistants review these signals, and those that are likely to represent an ADE or medication error are presented to reviewers who independently categorize them into ADEs, potential ADEs, medication errors, or exclusions. These incidents are also classified according to preventability, ameliorability, disability, severity, stage, and responsible person. These classifications, as well as the initial selection of incidents, have been evaluated for agreement between reviewers and the level of agreement found ranged from satisfactory to excellent (kappa = 0.32-0.98). The method of ADE and medication error detection and classification described is feasible and has good reliability. It can be used in various clinical settings to measure and improve medication safety.
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Affiliation(s)
- T Morimoto
- Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120-1613, USA
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Abstract
Abstract
Patient Safety Leading Article Series, 2004 Dr David W Bates of Harvard Medical School, and Brigham and Women's Hospital, Boston, has for some years had a major interest in information technology in healthcare. Here, he continues our ‘Patient Safety’ series of leading articles, exploring how the tools of the modern era can help avoid harm in the surgical arena.
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Affiliation(s)
- D W Bates
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 0211J, USA.
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Kittler AF, Wald JS, Volk LA, Pizziferri L, Jagannath Y, Harris C, Lippincott M, Yu T, Hobbs J, Bates DW. The role of primary care non-physician clinic staff in e-mail communication with patients. Int J Med Inform 2004; 73:333-40. [PMID: 15135751 DOI: 10.1016/j.ijmedinf.2004.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2003] [Revised: 02/09/2004] [Accepted: 02/27/2004] [Indexed: 11/24/2022]
Abstract
BACKGROUND Few studies have explicitly addressed how e-mail technology may affect non-physician clinic staff, even though these staff typically manage tasks well suited to e-mail communication such as requests for prescription renewals, laboratory and test results, and referral authorizations. GOAL We conducted a survey of staff members at 10 primary care clinics in Boston to further evaluate non-physician staff attitudes towards e-mail use with patients. We subsequently re-surveyed staff at three of these clinics after the implementation of Patient Gateway, an application designed to facilitate secure electronic communication between patients and the clinics. RESULTS Before Patient Gateway implementation, 88% of surveyed staff were already using e-mail at least once a day for work-related communication. Many of these staff members (24%) were already using e-mail with patients. Forty-eight percent of staff members thought that increasing e-mail use with patients could improve the quality of care their practices delivered. However, staff reported having some hesitations about increasing e-mail use with patients, mostly relating to security, confidentiality, and workload. After Patient Gateway implementation, users reported high satisfaction with the application and staff in general (users and non-users of Patient Gateway) felt more enthusiastic about increasing e-mail use with patients. CONCLUSIONS In order to maximize the potential of staff-patient e-mail, it is important that concerns relating to security, confidentiality, and workflow are addressed, and patients must be given guidelines for the appropriate use of e-mail. Secure applications designed with these issues in mind are likely to be well received by staff members, and in turn physicians.
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Affiliation(s)
- A F Kittler
- Partners HealthCare Information Systems, Department of Clinical Analysis, Wellesley, MA, USA
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Murff HJ, Gandhi TK, Karson AK, Mort EA, Poon EG, Wang SJ, Fairchild DG, Bates DW. Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory decision support systems. Int J Med Inform 2004; 71:137-49. [PMID: 14519406 DOI: 10.1016/s1386-5056(03)00133-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Failures to follow-up abnormal test results are common in ambulatory care. Information systems could assist providers with abnormal test result tracking, yet little is known about primary care providers attitudes toward outpatient decision support systems. METHODS A cross-sectional survey of 216 primary care physicians (PCPs) that utilize a single electronic medical record (EMR) without computer-based clinical decision support. RESULTS The overall response rate was 65% (140/216). Less than one-third of the respondents were satisfied with their current system to manage abnormal laboratory, radiographs, Pap smear, or mammograms results. Only 15% of providers were satisfied with their system to notify patients of abnormal results. Over 90% of respondents felt automated systems to track abnormal test results would be useful. Seventy-nine percent of our respondents believed that they could comply better with guidelines through electronic clinical reminders. CONCLUSIONS Most PCPs were not satisfied with their methods for tracking abnormal results. Respondents believed that clinical decision support systems (CDSS) would be useful and could improve their ability to track abnormal results.
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Affiliation(s)
- H J Murff
- Vanderbilt University Medical Center and Department of Veterans Affairs, TVH, GRECC Unit, 1310 24th Avenue South, Nashville, TN 37212, USA.
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Hope CJ, Seger AC, Overhage JM, Gandhi TK, Teal EY, Mills VL, Bates DW, Murray MD. Use of electronic medical records to detect adverse drug events and medication errors in outpatients. Clin Pharmacol Ther 2003. [DOI: 10.1016/s0009-9236(03)90710-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Medication errors occur frequently and have significant clinical and financial consequences. Several types of information technologies can be used to decrease rates of medication errors. Computerized physician order entry with decision support significantly reduces serious inpatient medication error rates in adults. Other available information technologies that may prove effective for inpatients include computerized medication administration records, robots, automated pharmacy systems, bar coding, "smart" intravenous devices, and computerized discharge prescriptions and instructions. In outpatients, computerization of prescribing and patient oriented approaches such as personalized web pages and delivery of web based information may be important. Public and private mandates for information technology interventions are growing, but further development, application, evaluation, and dissemination are required.
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Affiliation(s)
- R Kaushal
- Division of General Internal Medicine, Brigham and Women's Hospital, Partners HealthCare System, Harvard Medical School, Boston, MA, USA.
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Shu K, Boyle D, Spurr C, Horsky J, Heiman H, O'Connor P, Lepore J, Bates DW. Comparison of time spent writing orders on paper with computerized physician order entry. Stud Health Technol Inform 2002; 84:1207-11. [PMID: 11604922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Computerized physician order entry (CPOE) has been shown to improve quality, and to reduce resource utilization, but most available data suggest that it takes longer to enter orders using CPOE. We had previously implemented a CPOE system, and elected to evaluate its impact on physician time in the new setting. To do this, we performed a prospective study using random reminder methodology. Key findings were that interns spent 9.0% of their time ordering with CPOE, compared to 2.1% before, although CPOE saved them an additional 2% of time, so that the net difference was 5% of their total time. However, this is counterbalanced by decreased time for other personnel such as nursing and pharmacy, and by the quality and efficiency changes. We conclude that while CPOE has many benefits, it represents a major process change, and organizations must factor this in when they implement it.
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Affiliation(s)
- K Shu
- Information Systems, Partners HealthCare System, Boston, MA, USA
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Chertow GM, Lee J, Kuperman GJ, Burdick E, Horsky J, Seger DL, Lee R, Mekala A, Song J, Komaroff AL, Bates DW. Guided medication dosing for inpatients with renal insufficiency. JAMA 2001; 286:2839-44. [PMID: 11735759 DOI: 10.1001/jama.286.22.2839] [Citation(s) in RCA: 281] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Usual drug-prescribing practices may not consider the effects of renal insufficiency on the disposition of certain drugs. Decision aids may help optimize prescribing behavior and reduce medical error. OBJECTIVE To determine if a system application for adjusting drug dose and frequency in patients with renal insufficiency, when merged with a computerized order entry system, improves drug prescribing and patient outcomes. DESIGN, SETTING, AND PATIENTS Four consecutive 2-month intervals consisting of control (usual computerized order entry) alternating with intervention (computerized order entry plus decision support system), conducted in September 1997-April 1998 with outcomes assessed among a consecutive sample of 17 828 adults admitted to an urban tertiary care teaching hospital. INTERVENTION Real-time computerized decision support system for prescribing drugs in patients with renal insufficiency. During intervention periods, the adjusted dose list, default dose amount, and default frequency were displayed to the order-entry user and a notation was provided that adjustments had been made based on renal insufficiency. During control periods, these recommended adjustments were not revealed to the order-entry user, and the unadjusted parameters were displayed. MAIN OUTCOME MEASURES Rates of appropriate prescription by dose and frequency, length of stay, hospital and pharmacy costs, and changes in renal function, compared among patients with renal insufficiency who were hospitalized during the intervention vs control periods. RESULTS A total of 7490 patients were found to have some degree of renal insufficiency. In this group, 97 151 orders were written on renally cleared or nephrotoxic medications, of which 14 440 (15%) had at least 1 dosing parameter modified by the computer based on renal function. The fraction of prescriptions deemed appropriate during the intervention vs control periods by dose was 67% vs 54% (P<.001) and by frequency was 59% vs 35% (P<.001). Mean (SD) length of stay was 4.3 (4.5) days vs 4.5 (4.8) days in the intervention vs control periods, respectively (P =.009). There were no significant differences in estimated hospital and pharmacy costs or in the proportion of patients who experienced a decline in renal function during hospitalization. CONCLUSIONS Guided medication dosing for inpatients with renal insufficiency appears to result in improved dose and frequency choices. This intervention demonstrates a way in which computer-based decision support systems can improve care.
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Affiliation(s)
- G M Chertow
- Department of Medicine Research, UCSF Laurel Heights, 3333 California St, Suite 430, San Francisco, CA 94118, USA.
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Hsu CY, Bates DW, Kuperman GJ, Curhan GC. Blood pressure and angiotensin converting enzyme inhibitor use in hypertensive patients with chronic renal insufficiency. Am J Hypertens 2001; 14:1219-25. [PMID: 11775130 DOI: 10.1016/s0895-7061(01)02202-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hypertension treatment is important in managing chronic renal insufficiency (CRI). Little is known, however, about the blood pressure (BP) control achieved or the pattern of antihypertensive drug prescription among CRI patients. METHODS Using computerized medical records, we studied 3,089 adult hypertensive subjects treated at Brigham and Women's Hospital (Boston, MA) from 1990 through 1998. All subjects had at least two serum creatinine measurements 2 years apart, at least two BP readings, and online weight (to estimate Cockcroft-Gault creatinine clearance [CrCl]). RESULTS The average mean arterial pressure over time (mean MAP) was 103 +/- 9 mm Hg among those with CrCI >60 mL/min, 102 t 9 mm Hg among those with CrCl 41 to 60 mL/min. and 101 +/- 9 mm Hg among those with CrCl 21 to 40 mL/min. There were no significant differences in mean MAP among the different categories of renal function in the multivariate analysis (P = .26 for trend). The proportion of patients with final systolic BP < 160 mm Hg and diastolic BP <90 mm Hg was 68% and did not vary with renal function (P = .68 for trend). The proportion of subjects who were prescribed ACE inhibitors was 38% among those with CrCl >60 mL/min, 36% among those with CrCI 41 to 60 mL/min, and only 27% among those with CrCl 21 to 40 mL/min (P = .003 for trend). CONCLUSIONS The BP control achieved among hypertensive CRI subjects, although no worse than that among those without CRI, was found to be suboptimal. Patients with CrCl 21 to 40 mL/min were less likely to be prescribed ACE inhibitors than were those with CrCl >60 mL/min. Improvement is needed in the clinical management of these factors that can influence the progression of CRI.
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Affiliation(s)
- C Y Hsu
- Division of Nephrology, University of California, San Francisco 94143-0532, USA.
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Abstract
In this study, we develop and internally validate a clinical prediction rule for in-hospital major adverse outcomes, defined as death, renal failure, reinfarction, cardiac arrest, cerebrovascular accident, or coma, in patients who underwent coronary artery bypass grafting (CABG). All adult patients (n = 9,498) who underwent a CABG and no other concomitant surgery at 12 academic medical centers from August 1993 to October 1995 were included in the study. We assessed in-hospital major adverse outcomes and their predictors using information on admission, coronary angiography, and postoperative hospital course. Predictor variables were limited to information available before the procedure, and outcome variables were represented only by events that occurred postoperatively. We developed and internally validated a clinical prediction rule for any major adverse outcome after CABG. The rule's ability to discriminate outcomes and its calibration were assessed using receiver-operating characteristic analysis and the Hosmer-Lemeshow goodness-of-fit statistic, respectively. A major adverse outcome occurred in 6.5% of patients in the derivation set and 7.2% in the validation set. Death occurred in 2.5% of patients in the derivation set and 2.2% in the validation set. Sixteen variables were independently correlated with major adverse outcomes, with the risk score value attributed to each risk factor ranging from 2 to 12 points. The rule stratified patients into 6 levels of risk based on the total risk score. The spread in probability between the lowest and highest risk groups of having a major adverse outcome was 1.7% to 32.3% in the derivation set and 2.2% to 22.3% in the validation set. The prediction model performed well in both outcome discrimination and calibration. Thus, this clinical prediction rule allows accurate stratification of potential CABG candidates before surgery according to the risk of experiencing a major adverse outcome postoperatively.
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Affiliation(s)
- E B Fortescue
- Division of General Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
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Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA 2001; 286:1610-20. [PMID: 11585485 DOI: 10.1001/jama.286.13.1610] [Citation(s) in RCA: 188] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT While most meniscal or ligamentous knee injuries heal with nonoperative treatments, a subset should be treated with arthroscopic or open surgery. OBJECTIVE To analyze the accuracy of the clinical examination for meniscal or ligamentous knee injuries. DATA SOURCES MEDLINE (1966-December 31, 2000) and HealthSTAR (1975-December 31, 2000) databases were searched for English-language articles describing the diagnostic accuracy of individual examination items for the knee and a combination of physical examination items (composite examination). Other data sources included reference lists from relevant articles. STUDY SELECTION Studies selected for data extraction were those that compared the performance of the physical examination of the knee with a reference standard, such as arthroscopy, arthrotomy, or magnetic resonance imaging. Eighty-eight articles were identified, of which 23 (26%) met inclusion criteria. DATA EXTRACTION A rheumatologist and an orthopedic surgeon independently reviewed each article using a standardized rating scale that scored the assembly of the study, the relevance of the patients enrolled, the appropriateness of the reference standard, and the blinding of the examiner. DATA SYNTHESIS Summary likelihood ratios (LRs) were estimated from random effects models. The summary LRs for physical examination for tears of the anterior cruciate ligament, using the anterior drawer test, were 3.8 (95% confidence interval [CI], 0.7-22.0) for a positive examination and 0.30 (95% CI, 0.05-1.50) for a negative examination; the Lachman test, 25.0 (95% CI, 2.7-651.0) and 0.1 (95% CI, 0.0-0.4); and the composite assessment, 25.0 (95% CI, 2.1-306.0) and 0.04 (95% CI, 0.01-0.48), respectively. The LRs could not be generated for any specific examination maneuver for a posterior cruciate ligament tear, but the composite assessment had an LR of 21.0 (95% CI, 2.1-205.0) for a positive examination and 0.05 (95% CI, 0.01-0.50) for a negative examination. Determination of meniscal lesions, using McMurray test, had an LR of 1.3 (95% CI, 0.9-1.7) for a positive examination and 0.8 (95% CI, 0.6-1.1) for a negative examination; joint line tenderness, 0.9 (95% CI, 0.8-1.0) and 1.1 (95% CI, 1.0-1.3); and the composite assessment, 2.7 (95% CI, 1.4-5.1) and 0.4 (95% CI, 0.2-0.7), respectively. CONCLUSION The composite examination for specific meniscal or ligamentous injuries of the knee performed much better than specific maneuvers, suggesting that synthesis of a group of examination maneuvers and historical items may be required for adequate diagnosis.
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Affiliation(s)
- D H Solomon
- Department of Orthopedic Surgery, The Cleveland Clinic, 9500 Euclid Ave, Desk A41, Cleveland, OH 44195, USA
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Abstract
BACKGROUND While parenteral amphotericin B is an effective therapy for serious fungal infections, it frequently causes acute renal failure (ARF). This study identified correlates of ARF in amphotericin B therapy and used them to develop clinical prediction rules. METHODS All 643 inpatients receiving parenteral amphotericin B therapy at one tertiary care hospital were included. Data regarding correlates were obtained both electronically and from manual chart review in a subsample of 231 patients. ARF was defined as a 50% increase in the baseline creatinine with a peak > or =2.0 mg/dL. RESULTS Among 643 episodes, ARF developed in 175 (27%). In the larger group, the only independent correlate of ARF was male gender (OR = 2.2, 95% CI, 1.5 to 3.3). In the subsample (N = 231), independent correlates of ARF were maximum daily amphotericin dosage, location at the time of initiation of amphotericin therapy, and concomitant use of cyclosporine. These data were used to develop two clinical prediction rules. A rule using only data available at initiation of therapy stratified patients into groups with probability of ARF ranging from 15 to 54%, while a rule including data available during therapy (maximum daily dose) stratified patients into groups with probability of ARF ranging from 4 to 80%. CONCLUSIONS Acute renal failure occurred in a quarter of the patients. Correlates of ARF at the beginning and during the course of amphotericin therapy were identified and then combined to allow stratification according to ARF risk. These data also provide evidence for guidelines for the selection of patients for alternative therapies.
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Affiliation(s)
- D W Bates
- Division of General Medicine, and the Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Fairchild DG, McLoughlin KS, Gharib S, Horsky J, Portnow M, Richter J, Gagliano N, Bates DW. Productivity, quality, and patient satisfaction: comparison of part-time and full-time primary care physicians. J Gen Intern Med 2001; 16:663-7. [PMID: 11679033 PMCID: PMC1495282 DOI: 10.1111/j.1525-1497.2001.01111.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Although few data are available, many believe that part-time primary care physicians (PCPs) are less productive and provide lower quality care than full-time PCPs. Some insurers exclude part-time PCPs from their provider networks. OBJECTIVE To compare productivity, quality of preventive care, patient satisfaction, and risk-adjusted resource utilization of part-time and full-time PCPs. DESIGN Retrospective cohort study. SETTING Boston. PARTICIPANTS PCPs affiliated with 2 academic outpatient primary care networks. MEASUREMENTS PCP productivity, patient satisfaction, resource utilization, and compliance with screening guidelines. RESULTS Part-time PCP productivity was greater than that of full-time PCPs (2.1 work relative value units (RVUs)/bookable clinical hour versus 1.3 work RVUs/bookable clinical hour, P< .01). A similar proportion of part-time PCPs (80%) and full-time PCPs (75%) met targets for mammography, Pap smears, and cholesterol screening (P = .67). After adjusting for clinical case mix, practice location, gender, board certification status, and years in practice, resource utilization of part-time PCPs (138 dollars [95% confidence interval (CI), 108 dollars to 167 dollars]) was similar to that of full-time PCPs (139 dollars [95% CI, 108 dollars to 170 dollars], P = .92). Patient satisfaction was similar for part-time and full-time PCPs. CONCLUSIONS In these academic primary care practices, rates of patient satisfaction, compliance with screening guidelines, and resource utilization were similar for part-time PCPs compared to full-time PCPs. Productivity per clinical hour was markedly higher for part-time PCPs. Despite study limitations, these data suggest that academic part-time PCPs are at least as efficient as full-time PCPs and that the quality of their work is similar.
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Affiliation(s)
- D G Fairchild
- Division of General Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Kuperman GJ, Teich JM, Gandhi TK, Bates DW. Patient safety and computerized medication ordering at Brigham and Women's Hospital. Jt Comm J Qual Improv 2001; 27:509-21. [PMID: 11593885 DOI: 10.1016/s1070-3241(01)27045-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Medications are important therapeutic tools in health care, yet creating safe medication processes is challenging for many reasons. Computerized physician order entry (CPOE), one important way that technology can be used to improve the medication process, has been in place at Brigham and Women's Hospital (BWH; Boston) since 1993. CPOE AT BWH The CPOE application, designed and developed internally by the BWH information systems team, allows physicians and other clinicians to enter all patient orders into the computer. Physicians enter 85% of orders, with the remainder entered electronically by other clinicians. CPOE AND SAFE MEDICATION USE The CPOE application at BWH includes several features designed to improve medication safety--structural features (for example, required fields, use of pick lists), enhanced workflow features (order sets, standard scales for insulin and potassium), alerts and reminders (drug-drug and drug-allergy interaction checking), and adjunct features (the pharmacy system, access to online reference information). RESULTS AT BWH Studies of the impact of CPOE on physician decision making and patient safety at BWH include assessment of CPOE's impact on the serious medication error and the preventable adverse drug event rate, the impact of computer guidelines on the use of vancomycin, the impact of guidelines on the use of heparin in patients at bed rest, and the impact of dosing suggestions on excessive dosing. CONCLUSION CPOE and several forms of clinical decision support targeted at increasing patient safety have substantially decreased the frequency of serious medication errors and have had an even bigger impact on the overall medication error rate.
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Affiliation(s)
- G J Kuperman
- Department of Information Systems, Partners HealthCare System, Harvard Medical School, Boston, MA, USA.
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Kaushal R, Barker KN, Bates DW. How can information technology improve patient safety and reduce medication errors in children's health care? Arch Pediatr Adolesc Med 2001; 155:1002-7. [PMID: 11529801 DOI: 10.1001/archpedi.155.9.1002] [Citation(s) in RCA: 141] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Medication errors are common, costly, and injurious to patients. OBJECTIVE To review the role of information technology in decreasing pediatric medication errors in both inpatient and outpatient settings. DESIGN We performed a literature review of current information technology interventions. RESULTS Several types of information technology will likely reduce the frequency of medication errors, although insufficient data exists for many technologies, and most available data come from adult settings. Computerized physician order entry with decision support substantially decreases the frequency of serious inpatient medication errors in adults. Certain other inpatient information technologies may be beneficial even though less evidence is currently available. These include computerized medication administration records, robots, automated pharmacy systems, bar coding, "smart" intravenous devices, and computerized discharge prescriptions and instructions. In the outpatient setting, where adherence is especially important, personalized Web pages and World Wide Web-based information have substantial potential. CONCLUSIONS Medication errors are an important problem in pediatrics. Information technology interventions have great potential for reducing the frequency of errors. The magnitude of benefits may be even greater in pediatrics than in adult medicine because of the need for weight-based dosing. Further development, application, evaluation, and dissemination of pediatric-specific information technology interventions are essential.
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Affiliation(s)
- R Kaushal
- Department of Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
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