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Fletcher E, Burns A, Wiering B, Lavu D, Shephard E, Hamilton W, Campbell JL, Abel G. Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review. BMC Prim Care 2023; 24:23. [PMID: 36670354 PMCID: PMC9857918 DOI: 10.1186/s12875-023-01973-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow. METHODS A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed. RESULTS The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue". CONCLUSIONS The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.
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Affiliation(s)
- Emily Fletcher
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Alex Burns
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Bianca Wiering
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Deepthi Lavu
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Elizabeth Shephard
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Willie Hamilton
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - John L. Campbell
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Gary Abel
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
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Kearney AM, Kalainov DM, Zumpf KB, Mehta M, Bai J, Petito LC. Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System. J Hand Surg Am 2022; 47:1035-1044. [PMID: 36184274 DOI: 10.1016/j.jhsa.2022.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Received: 01/15/2022] [Revised: 07/02/2022] [Accepted: 08/10/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE We hypothesized that a pain management prescribing tool embedded in the electronic health record system of a multihospital health care system would decrease prescription opioids for postoperative pain by hand, orthopedic, plastic, and spine surgeons. METHODS A prescribing tool for postoperative pain was designed for hand, orthopedic, plastic, and spine surgeons and implemented into electronic discharge order sets in a 10-hospital health care system. Stakeholders were educated on tool use in person and/or by email on 2 occasions. A dashboard was created to monitor opioid pill quantities and morphine milligram equivalents (MMEs) prescribed. Overall compliance with the suggested opioid amounts was assessed for 20 months after tool implementation. A subgroup of 6 hand surgeons, one of whom was instrumental in designing the tool, were evaluated for MMEs prescribed, opioid refills, patient emergency room visits, and patient readmissions within 30 days after discharge. Comparisons in this subgroup were made from 12 months before to 15 months after tool implementation. RESULTS The mean system-wide compliance with the suggested opioid pill quantities and MMEs prescribed in all 4 specialties improved by less than 5%. In the subgroup of hand surgeons, 5 of whom championed tool use, prescribed MMEs decreased by 10% during each of the 4 quarters before launching the tool and contracted an additional 26% in the first quarter after tool implementation. Opioid refills held steady at 5%, and there were no emergency room visits or readmissions within 30 days after discharge in this patient subgroup. CONCLUSIONS The prescribing tool had a negligible impact on system-wide compliance with suggested prescription opioid pill quantities and MMEs. In a small group of surgeons who championed the use of the tool, there was a significant and sustained decline in MMEs prescribed without adversely impacting patient refills, emergency room visits, or readmissions. CLINICAL RELEVANCE An electronic prescribing tool to assist surgeons in lowering opioid prescription pill quantities and MMEs may have a negligible impact on prescribing behavior in a multihospital health care system.
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Affiliation(s)
- Aaron M Kearney
- Northwestern University Division of Plastic Surgery, Chicago, IL
| | - David M Kalainov
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL; Northwestern Medicine Center for Surgery of the Hand, Chicago, IL.
| | - Katelyn B Zumpf
- Northwestern University Department of Preventive Medicine, Chicago, IL
| | - Manish Mehta
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL
| | - Jennifer Bai
- Northwestern University Division of Plastic Surgery, Chicago, IL
| | - Lucia C Petito
- Northwestern University Department of Preventive Medicine, Chicago, IL
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Greenberg JK, Otun A, Nasraddin A, Brownson RC, Kuppermann N, Limbrick DD, Yen PY, Foraker RE. Electronic clinical decision support for children with minor head trauma and intracranial injuries: a sociotechnical analysis. BMC Med Inform Decis Mak 2021; 21:161. [PMID: 34011315 PMCID: PMC8132484 DOI: 10.1186/s12911-021-01522-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 05/09/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Current management of children with minor head trauma (MHT) and intracranial injuries is not evidence-based and may place some children at risk of harm. Evidence-based electronic clinical decision support (CDS) for management of these children may improve patient safety and decrease resource use. To guide these efforts, we evaluated the sociotechnical environment impacting the implementation of electronic CDS, including workflow and communication, institutional culture, and hardware and software infrastructure, among other factors. METHODS Between March and May, 2020 semi-structured qualitative focus group interviews were conducted to identify sociotechnical influences on CDS implementation. Physicians from neurosurgery, emergency medicine, critical care, and pediatric general surgery were included, along with information technology specialists. Participants were recruited from nine health centers in the United States. Focus group transcripts were coded and analyzed using thematic analysis. The final themes were then cross-referenced with previously defined sociotechnical dimensions. RESULTS We included 28 physicians and four information technology specialists in seven focus groups (median five participants per group). Five physicians were trainees and 10 had administrative leadership positions. Through inductive thematic analysis, we identified five primary themes: (1) clinical impact; (2) stakeholders and users; (3) tool content; (4) clinical practice integration; and (5) post-implementation evaluation measures. Participants generally supported using CDS to determine an appropriate level-of-care for these children. However, some had mixed feelings regarding how the tool could best be used by different specialties (e.g. use by neurosurgeons versus non-neurosurgeons). Feedback from the interviews helped refine the tool content and also highlighted potential technical and workflow barriers to address prior to implementation. CONCLUSIONS We identified key factors impacting the implementation of electronic CDS for children with MHT and intracranial injuries. These results have informed our implementation strategy and may also serve as a template for future efforts to implement health information technology in a multidisciplinary, emergency setting.
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Affiliation(s)
- Jacob K Greenberg
- Departments of Neurological Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Box 8057, St. Louis, MO, 63110, USA.
| | - Ayodamola Otun
- Departments of Neurological Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Box 8057, St. Louis, MO, 63110, USA
| | - Azzah Nasraddin
- Brown School of Social Work, Washington University School of Medicine, St. Louis, MO, USA
| | - Ross C Brownson
- Brown School of Social Work, Washington University School of Medicine, St. Louis, MO, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis, Davis, CA, USA
| | - David D Limbrick
- Departments of Neurological Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Box 8057, St. Louis, MO, 63110, USA
| | - Po-Yin Yen
- Institute for Informatics, Washington University School of Medicine, St. Louis, MO, USA
| | - Randi E Foraker
- Institute for Informatics, Washington University School of Medicine, St. Louis, MO, USA
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Levy AE, Shah NR, Matheny ME, Reeves RM, Gobbel GT, Bradley SM. Determining post-test risk in a national sample of stress nuclear myocardial perfusion imaging reports: Implications for natural language processing tools. J Nucl Cardiol 2019; 26:1878-1885. [PMID: 29696484 PMCID: PMC6202272 DOI: 10.1007/s12350-018-1275-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 02/26/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Reporting standards promote clarity and consistency of stress myocardial perfusion imaging (MPI) reports, but do not require an assessment of post-test risk. Natural Language Processing (NLP) tools could potentially help estimate this risk, yet it is unknown whether reports contain adequate descriptive data to use NLP. METHODS Among VA patients who underwent stress MPI and coronary angiography between January 1, 2009 and December 31, 2011, 99 stress test reports were randomly selected for analysis. Two reviewers independently categorized each report for the presence of critical data elements essential to describing post-test ischemic risk. RESULTS Few stress MPI reports provided a formal assessment of post-test risk within the impression section (3%) or the entire document (4%). In most cases, risk was determinable by combining critical data elements (74% impression, 98% whole). If ischemic risk was not determinable (25% impression, 2% whole), inadequate description of systolic function (9% impression, 1% whole) and inadequate description of ischemia (5% impression, 1% whole) were most commonly implicated. CONCLUSIONS Post-test ischemic risk was determinable but rarely reported in this sample of stress MPI reports. This supports the potential use of NLP to help clarify risk. Further study of NLP in this context is needed.
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Affiliation(s)
- Andrew E. Levy
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nishant R. Shah
- Division of Cardiology, Department of Medicine, Brown University Alpert Medical School, Providence, RI, USA
- Center for Evidence Synthesis in Health, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Michael E. Matheny
- Health Services Research & Development; VA Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Ruth M. Reeves
- Health Services Research & Development; VA Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Glenn T. Gobbel
- Health Services Research & Development; VA Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Steven M. Bradley
- Cardiovascular Medicine, VA Eastern Colorado Healthcare System, Denver, CO, USA
- Center for Healthcare Delivery Innovation, Minneapolis Heart Institute, Minneapolis, MN, USA
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Moore HJ, Nixon C, Tariq A, Emery J, Hamilton W, Hoare Z, Kershenbaum A, Neal RD, Ukoumunne OC, Usher-Smith J, Walter FM, Whyte S, Rubin G. Evaluating a computer aid for assessing stomach symptoms (ECASS): study protocol for a randomised controlled trial. Trials 2016; 17:184. [PMID: 27044367 PMCID: PMC4820978 DOI: 10.1186/s13063-016-1307-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/19/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND For most cancers, only a minority of patients have symptoms meeting the National Institute for Health and Clinical Excellence guidance for urgent referral. For gastro-oesophageal cancers, the 'alarm' symptoms of dysphagia and weight loss are reported by only 32 and 8 % of patients, respectively, and their presence correlates with advanced-stage disease. Electronic clinical decision-support tools that integrate with clinical computer systems have been developed for general practice, although uncertainty remains concerning their effectiveness. The objectives of this trial are to optimise the intervention and establish the acceptability of both the intervention and randomisation, confirm the suitability and selection of outcome measures, finalise the design for the phase III definitive trial, and obtain preliminary estimates of the intervention effect. METHODS/DESIGN This is a two-arm, multi-centre, cluster-randomised, controlled phase II trial design, which will extend over a 16-month period, across 60 general practices within the North East and North Cumbria and the Eastern Local Clinical Research Network areas. Practices will be randomised to receive either the intervention (the electronic clinical decision-support tool) or to act as a control (usual care). From these practices, we will recruit 3000 adults who meet the trial eligibility criteria and present to their GP with symptoms suggestive of gastro-oesophageal cancer. The main measures are the process data, which include the practitioner outcomes, service outcomes, diagnostic intervals, health economic outcomes, and patient outcomes. One-on-one interviews in a sub-sample of 30 patient-GP dyads will be undertaken to understand the impact of the use or non-use of the electronic clinical decision-support tool in the consultation. A further 10-15 GPs will be interviewed to identify and gain an understanding of the facilitators and constraints influencing implementation of the electronic clinical decision-support tool in practice. DISCUSSION We aim to generate new knowledge on the process measures regarding the use of electronic clinical decision-support tools in primary care in general and to inform a subsequent definitive phase III trial. Preliminary data on the impact of the support tool on resource utilisation and health care costs will also be collected. TRIAL REGISTRATION ISRCTN Registry, ISRCTN12595588 .
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Affiliation(s)
- Helen J. Moore
- />School of Medicine, Pharmacy & Health, Durham University, Wolfson Research Institute, Queens Campus, Thornaby, TS17 6BH UK
| | - Catherine Nixon
- />School of Medicine, Pharmacy & Health, Durham University, Wolfson Research Institute, Queens Campus, Thornaby, TS17 6BH UK
| | - Anisah Tariq
- />School of Medicine, Pharmacy & Health, Durham University, Wolfson Research Institute, Queens Campus, Thornaby, TS17 6BH UK
| | - Jon Emery
- />General Practice and Primary Health Care Academic Centre, The University of Melbourne, 200 Berkeley St, Carlton, VIC 3053 Australia
| | - Willie Hamilton
- />The Veysey Building, University of Exeter, College House, Exeter, EX1 2LU UK
| | - Zoë Hoare
- />NWORTH Clinical Trials Unit, Bangor University, Y Wern, Normal Site, Holyhead Road, Bangor, LL57 2PZ UK
| | - Anne Kershenbaum
- />Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, 2 Worts Causeway, Cambridge, CB1 8RN UK
| | - Richard D. Neal
- />North Wales Centre for Primary Care Research, Bangor University, Gwenfro Units 4-8, Wrexham Technology Park, Wrexham, LL13 7YP UK
| | - Obioha C. Ukoumunne
- />NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter, South Cloisters Building, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Juliet Usher-Smith
- />Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, 2 Worts Causeway, Cambridge, CB1 8RN UK
| | - Fiona M. Walter
- />Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, 2 Worts Causeway, Cambridge, CB1 8RN UK
| | - Sophie Whyte
- />School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Greg Rubin
- />School of Medicine, Pharmacy & Health, Durham University, Wolfson Research Institute, Queens Campus, Thornaby, TS17 6BH UK
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Graven M, Allen P, Smith I, MacDonald NE. Decline in mortality with the Belize Integrated Patient-Centred Country Wide Health Information System (BHIS) with embedded program management. Int J Med Inform 2013; 82:954-63. [PMID: 23834838 DOI: 10.1016/j.ijmedinf.2013.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [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: 11/26/2012] [Revised: 05/09/2013] [Accepted: 06/01/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Belize deployed a country-wide fully integrated patient centred health information system with eight embedded disease management algorithms and simple analytics in 2007 for $4 (Cad)/citizen. OBJECTIVES This study evaluated BHIS uptake by health care workers, and pre and post BHIS deployment mortality in selected areas and public health care expenditures. METHODS BHIS encounter data were compared to encounter data from required Ministry of Health reports from licensed health care entities. De-identified vital statistics death data for the eight BHIS protocol disease domains and three non-protocol domains were compared from 2005 to 2011. Belize population data came from the Statistical Institute of Belize (2005-2009) and from Belize census (2010) and estimate (2011). Public health system expenditures were compared by fiscal years (2000-2012). RESULTS BHIS captured over 90% healthcare encounters by year one, 95% by year two. Mortality rates decreased in the eight BHIS protocol domains (each 2005 vs. 2011, all p<0.02) vs. an increase or little change in the three domains without protocols. Hypertension related deaths dropped from 1st cause of death in 2003 to 9th by 2010. Public expenditures on healthcare steadily rose until 2009 but then declined slightly for the next 3 years. CONCLUSION For modest investment, BHIS was well accepted nationwide and following deployment, mortality in the eight BHIS disease management algorithm domains declined significantly and expenditures on public healthcare stabilized.
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Affiliation(s)
- Michael Graven
- Ministry of Health, Government of Belize, Belmopan, Belize; Department of Peadiatrics, Faculty of Medicine, Dalhousie University, etc, Halifax, Nova Scotia, Canada
| | - Peter Allen
- Ministry of Health, Government of Belize, Belmopan, Belize
| | - Ian Smith
- Ministry of Health, Government of Belize, Belmopan, Belize
| | - Noni E MacDonald
- Department of Peadiatrics, Faculty of Medicine, Dalhousie University, etc, Halifax, Nova Scotia, Canada.
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