Subjects -> MEDICAL SCIENCES (Total: 8448 journals)
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MEDICAL SCIENCES (2308 journals)                  1 2 3 4 5 6 7 8 | Last

Showing 1 - 200 of 3562 Journals sorted alphabetically
16 de Abril     Open Access   (Followers: 2)
3D Printing in Medicine     Open Access   (Followers: 4)
4 open     Open Access  
AADE in Practice     Hybrid Journal   (Followers: 6)
ABCS Health Sciences     Open Access   (Followers: 8)
Abia State University Medical Students' Association Journal     Full-text available via subscription   (Followers: 2)
AboutOpen     Open Access  
ACIMED     Open Access   (Followers: 1)
ACS Medicinal Chemistry Letters     Hybrid Journal   (Followers: 48)
Acta Bio Medica     Full-text available via subscription   (Followers: 2)
Acta Bioethica     Open Access  
Acta Bioquimica Clinica Latinoamericana     Open Access   (Followers: 1)
Acta Científica Estudiantil     Open Access  
Acta Facultatis Medicae Naissensis     Open Access   (Followers: 1)
Acta Herediana     Open Access  
Acta Informatica Medica     Open Access  
Acta Medica (Hradec Králové)     Open Access  
Acta Medica Bulgarica     Open Access  
Acta Medica Colombiana     Open Access   (Followers: 1)
Acta Médica Costarricense     Open Access   (Followers: 2)
Acta Medica Indonesiana     Open Access  
Acta Medica International     Open Access  
Acta medica Lituanica     Open Access  
Acta Medica Marisiensis     Open Access  
Acta Medica Martiniana     Open Access  
Acta Medica Nagasakiensia     Open Access   (Followers: 1)
Acta Medica Peruana     Open Access   (Followers: 2)
Acta Médica Portuguesa     Open Access  
Acta Medica Saliniana     Open Access  
Acta Scientiarum. Health Sciences     Open Access   (Followers: 2)
Acupuncture & Electro-Therapeutics Research     Full-text available via subscription   (Followers: 6)
Acupuncture and Natural Medicine     Open Access  
Addiction Science & Clinical Practice     Open Access   (Followers: 8)
Addictive Behaviors Reports     Open Access   (Followers: 10)
Adıyaman Üniversitesi Sağlık Bilimleri Dergisi / Health Sciences Journal of Adıyaman University     Open Access   (Followers: 1)
Adnan Menderes Üniversitesi Sağlık Bilimleri Fakültesi Dergisi     Open Access   (Followers: 1)
Advanced Biomedical Research     Open Access  
Advanced Health Care Technologies     Open Access   (Followers: 10)
Advanced Science, Engineering and Medicine     Partially Free   (Followers: 8)
Advanced Therapeutics     Hybrid Journal   (Followers: 1)
Advances in Bioscience and Clinical Medicine     Open Access   (Followers: 8)
Advances in Cell and Gene Therapy     Hybrid Journal   (Followers: 2)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 27)
Advances in Clinical Radiology     Full-text available via subscription   (Followers: 2)
Advances in Life Course Research     Hybrid Journal   (Followers: 10)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Medical Education and Practice     Open Access   (Followers: 32)
Advances in Medical Ethics     Open Access   (Followers: 1)
Advances in Medical Research     Open Access   (Followers: 2)
Advances in Medical Sciences     Hybrid Journal   (Followers: 9)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 6)
Advances in Medicine     Open Access   (Followers: 3)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 5)
Advances in Molecular Oncology     Open Access   (Followers: 2)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 7)
Advances in Parkinson's Disease     Open Access  
Advances in Phytomedicine     Full-text available via subscription  
Advances in Preventive Medicine     Open Access   (Followers: 6)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20)
Advances in Regenerative Medicine     Open Access   (Followers: 3)
Advances in Skeletal Muscle Function Assessment     Open Access  
Advances in Therapy     Hybrid Journal   (Followers: 5)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 15)
Advances in Virus Research     Full-text available via subscription   (Followers: 6)
Advances in Wound Care     Hybrid Journal   (Followers: 12)
Aerospace Medicine and Human Performance     Full-text available via subscription   (Followers: 13)
African Health Sciences     Open Access   (Followers: 4)
African Journal of Biomedical Research     Open Access   (Followers: 1)
African Journal of Clinical and Experimental Microbiology     Open Access   (Followers: 4)
African Journal of Laboratory Medicine     Open Access   (Followers: 2)
African Journal of Medical and Health Sciences     Open Access   (Followers: 3)
African Journal of Thoracic and Critical Care Medicine     Open Access  
African Journal of Trauma     Open Access   (Followers: 1)
Afrimedic Journal     Open Access   (Followers: 2)
Aggiornamenti CIO     Hybrid Journal   (Followers: 1)
AIDS Research and Human Retroviruses     Hybrid Journal   (Followers: 9)
AJOB Empirical Bioethics     Hybrid Journal   (Followers: 3)
AJSP: Reviews & Reports     Hybrid Journal  
Aktuelle Ernährungsmedizin     Hybrid Journal   (Followers: 4)
Al-Azhar Assiut Medical Journal     Open Access   (Followers: 2)
Al-Qadisiah Medical Journal     Open Access   (Followers: 2)
ALERTA : Revista Científica del Instituto Nacional de Salud     Open Access  
Alexandria Journal of Medicine     Open Access   (Followers: 1)
Allgemeine Homöopathische Zeitung     Hybrid Journal   (Followers: 3)
Alpha Omegan     Full-text available via subscription  
ALTEX : Alternatives to Animal Experimentation     Open Access   (Followers: 2)
Althea Medical Journal     Open Access   (Followers: 2)
American Journal of Biomedical Engineering     Open Access   (Followers: 15)
American Journal of Biomedical Research     Open Access   (Followers: 2)
American Journal of Biomedicine     Full-text available via subscription   (Followers: 7)
American Journal of Chinese Medicine, The     Hybrid Journal   (Followers: 4)
American Journal of Clinical Medicine Research     Open Access   (Followers: 8)
American Journal of Family Therapy     Hybrid Journal   (Followers: 10)
American Journal of Law & Medicine     Full-text available via subscription   (Followers: 11)
American Journal of Lifestyle Medicine     Hybrid Journal   (Followers: 6)
American Journal of Managed Care     Full-text available via subscription   (Followers: 12)
American Journal of Medical Case Reports     Open Access   (Followers: 1)
American Journal of Medical Sciences and Medicine     Open Access   (Followers: 4)
American Journal of Medicine     Hybrid Journal   (Followers: 51)
American Journal of Medicine and Medical Sciences     Open Access   (Followers: 1)
American Journal of Medicine Studies     Open Access   (Followers: 3)
American Journal of Medicine Supplements     Full-text available via subscription   (Followers: 3)
American Journal of the Medical Sciences     Hybrid Journal   (Followers: 12)
American Journal on Addictions     Hybrid Journal   (Followers: 10)
American medical news     Free   (Followers: 3)
American Medical Writers Association Journal     Full-text available via subscription   (Followers: 6)
Amyloid: The Journal of Protein Folding Disorders     Hybrid Journal   (Followers: 5)
Anales de la Facultad de Medicina     Open Access  
Anales de la Facultad de Medicina, Universidad de la República, Uruguay     Open Access  
Anales del Sistema Sanitario de Navarra     Open Access   (Followers: 1)
Analgesia & Resuscitation : Current Research     Hybrid Journal   (Followers: 6)
Anatolian Clinic the Journal of Medical Sciences     Open Access  
Anatomica Medical Journal     Open Access  
Anatomical Science International     Hybrid Journal   (Followers: 3)
Anatomical Sciences Education     Hybrid Journal   (Followers: 2)
Anatomy     Open Access   (Followers: 3)
Anatomy Research International     Open Access   (Followers: 4)
Angewandte Schmerztherapie und Palliativmedizin     Hybrid Journal  
Angiogenesis     Hybrid Journal   (Followers: 3)
Ankara Medical Journal     Open Access   (Followers: 2)
Ankara Üniversitesi Tıp Fakültesi Mecmuası     Open Access  
Annales de Pathologie     Full-text available via subscription  
Annales des Sciences de la Santé     Open Access  
Annales françaises d'Oto-rhino-laryngologie et de Pathologie Cervico-faciale     Full-text available via subscription   (Followers: 3)
Annals of African Medicine     Open Access   (Followers: 2)
Annals of Anatomy - Anatomischer Anzeiger     Hybrid Journal   (Followers: 3)
Annals of Bioanthropology     Open Access   (Followers: 5)
Annals of Biomedical Engineering     Hybrid Journal   (Followers: 19)
Annals of Biomedical Sciences     Full-text available via subscription   (Followers: 4)
Annals of Clinical Hypertension     Open Access  
Annals of Clinical Microbiology and Antimicrobials     Open Access   (Followers: 14)
Annals of Family Medicine     Open Access   (Followers: 15)
Annals of Health Research     Open Access   (Followers: 1)
Annals of Ibadan Postgraduate Medicine     Open Access  
Annals of Medical and Health Sciences Research     Open Access   (Followers: 7)
Annals of Medicine     Hybrid Journal   (Followers: 12)
Annals of Medicine and Surgery     Open Access   (Followers: 7)
Annals of Microbiology     Hybrid Journal   (Followers: 13)
Annals of Nigerian Medicine     Open Access   (Followers: 1)
Annals of Rehabilitation Medicine     Open Access  
Annals of Saudi Medicine     Open Access  
Annals of the College of Medicine, Mosul     Open Access   (Followers: 2)
Annals of the New York Academy of Sciences     Hybrid Journal   (Followers: 5)
Annals of The Royal College of Surgeons of England     Full-text available via subscription   (Followers: 3)
Annual Reports in Medicinal Chemistry     Full-text available via subscription   (Followers: 7)
Annual Reports on NMR Spectroscopy     Full-text available via subscription   (Followers: 5)
Annual Review of Medicine     Full-text available via subscription   (Followers: 17)
Anthropological Review     Open Access   (Followers: 24)
Anthropologie et santé     Open Access   (Followers: 5)
Antibiotics     Open Access   (Followers: 9)
Antibodies     Open Access   (Followers: 2)
Antibody Technology Journal     Open Access   (Followers: 1)
Antibody Therapeutics     Open Access  
Anuradhapura Medical Journal     Open Access  
Anwer Khan Modern Medical College Journal     Open Access   (Followers: 2)
Apmis     Hybrid Journal   (Followers: 1)
Apparence(s)     Open Access   (Followers: 1)
Applied Clinical Informatics     Hybrid Journal   (Followers: 4)
Applied Clinical Research, Clinical Trials and Regulatory Affairs     Hybrid Journal   (Followers: 2)
Applied Medical Informatics     Open Access   (Followers: 14)
Arab Journal of Nephrology and Transplantation     Open Access   (Followers: 1)
Archive of Clinical Medicine     Open Access   (Followers: 1)
Archive of Community Health     Open Access   (Followers: 1)
Archives Medical Review Journal / Arşiv Kaynak Tarama Dergisi     Open Access  
Archives of Asthma, Allergy and Immunology     Open Access  
Archives of Medical and Biomedical Research     Open Access   (Followers: 3)
Archives of Medical Laboratory Sciences     Open Access   (Followers: 1)
Archives of Medicine and Health Sciences     Open Access   (Followers: 4)
Archives of Medicine and Surgery     Open Access  
Archives of Trauma Research     Open Access   (Followers: 4)
Archivos de Medicina (Manizales)     Open Access  
ArgoSpine News & Journal     Hybrid Journal  
Arquivos Brasileiros de Oftalmologia     Open Access   (Followers: 1)
Arquivos de Ciências da Saúde     Open Access  
Arquivos de Medicina     Open Access  
Ars Medica : Revista de Ciencias Médicas     Open Access  
ARS Medica Tomitana     Open Access   (Followers: 1)
Art Therapy: Journal of the American Art Therapy Association     Hybrid Journal   (Followers: 17)
Arterial Hypertension     Open Access   (Followers: 1)
Artificial Intelligence in Medicine     Hybrid Journal   (Followers: 18)
Artificial Organs     Hybrid Journal   (Followers: 1)
ASHA Leader     Open Access   (Followers: 3)
Asia Pacific Family Medicine Journal     Open Access   (Followers: 2)
Asia Pacific Journal of Clinical Nutrition     Full-text available via subscription   (Followers: 13)
Asia Pacific Journal of Clinical Trials : Nervous System Diseases     Open Access  
Asian Bioethics Review     Full-text available via subscription   (Followers: 3)
Asian Biomedicine     Open Access   (Followers: 2)
Asian Journal of Cell Biology     Open Access   (Followers: 6)
Asian Journal of Health     Open Access   (Followers: 3)
Asian Journal of Medical and Biological Research     Open Access   (Followers: 5)
Asian Journal of Medical and Pharmaceutical Researches     Open Access   (Followers: 2)
Asian Journal of Medical Sciences     Open Access   (Followers: 2)
Asian Journal of Medicine and Health     Open Access   (Followers: 1)
Asian Journal of Research in Medical and Pharmaceutical Sciences     Open Access   (Followers: 1)
Asian Journal of Scientific Research     Open Access   (Followers: 3)
Asian Journal of Transfusion Science     Open Access   (Followers: 1)
Asian Medicine     Hybrid Journal   (Followers: 5)
Asian Pacific Journal of Cancer Prevention     Open Access  
ASPIRATOR : Journal of Vector-borne Disease Studies     Open Access  
Astrocyte     Open Access  

        1 2 3 4 5 6 7 8 | Last

Similar Journals
Journal Cover
Applied Clinical Informatics
Journal Prestige (SJR): 0.624
Citation Impact (citeScore): 1
Number of Followers: 4  
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 1869-0327
Published by Thieme Publishing Group Homepage  [239 journals]
  • Reducing Alert Burden in Electronic Health Records: State of the Art
           Recommendations from Four Health Systems
    • Authors: McGreevey; John D., Mallozzi, Colleen P., Perkins, Randa M., Shelov, Eric, Schreiber, Richard
      Pages: 001 - 012
      Abstract: Background Electronic health record (EHR) alert fatigue, while widely recognized as a concern nationally, lacks a corresponding comprehensive mitigation plan. Objectives The goal of this manuscript is to provide practical guidance to clinical informaticists and other health care leaders who are considering creating a program to manage EHR alerts. Methods This manuscript synthesizes several approaches and recommendations for better alert management derived from four U.S. health care institutions that presented their experiences and recommendations at the American Medical Informatics Association 2019 Clinical Informatics Conference in Atlanta, Georgia, United States. The assembled health care institution leaders represent academic, pediatric, community, and specialized care domains. We describe governance and management, structural concepts and components, and human–computer interactions with alerts, and make recommendations regarding these domains based on our experience supplemented with literature review. This paper focuses on alerts that impact bedside clinicians. Results The manuscript addresses the range of considerations relevant to alert management including a summary of the background literature about alerts, alert governance, alert metrics, starting an alert management program, approaches to evaluating alerts prior to deployment, and optimization of existing alerts. The manuscript includes examples of alert optimization successes at two of the represented institutions. In addition, we review limitations on the ability to evaluate alerts in the current state and identify opportunities for further scholarship. Conclusion Ultimately, alert management programs must strive to meet common goals of improving patient care, while at the same time decreasing the alert burden on clinicians. In so doing, organizations have an opportunity to promote the wellness of patients, clinicians, and EHRs themselves.
      Citation: Appl Clin Inform 2020; 11: 001-012
      PubDate: 2020-01-01T00:00:00+0100
      DOI: 10.1055/s-0039-3402715
      Issue No: Vol. 11, No. 01 (2020)
  • Transforming French Electronic Health Records into the Observational
           Medical Outcome Partnership's Common Data Model: A Feasibility Study
    • Authors: Lamer; Antoine, Depas, Nicolas, Doutreligne, Matthieu, Parrot, Adrien, Verloop, David, Defebvre, Marguerite-Marie, Ficheur, Grégoire, Chazard, Emmanuel, Beuscart, Jean-Baptiste
      Pages: 013 - 022
      Abstract: Background Common data models (CDMs) enable data to be standardized, and facilitate data exchange, sharing, and storage, particularly when the data have been collected via distinct, heterogeneous systems. Moreover, CDMs provide tools for data quality assessment, integration into models, visualization, and analysis. The observational medical outcome partnership (OMOP) provides a CDM for organizing and standardizing databases. Common data models not only facilitate data integration but also (and especially for the OMOP model) extends the range of available statistical analyses. Objective This study aimed to evaluate the feasibility of implementing French national electronic health records in the OMOP CDM. Methods The OMOP's specifications were used to audit the source data, specify the transformation into the OMOP CDM, implement an extract–transform–load process to feed data from the French health care system into the OMOP CDM, and evaluate the final database. Results Seventeen vocabularies corresponding to the French context were added to the OMOP CDM's concepts. Three French terminologies were automatically mapped to standardized vocabularies. We loaded nine tables from the OMOP CDM's “standardized clinical data” section, and three tables from the “standardized health system data” section. Outpatient and inpatient data from 38,730 individuals were integrated. The median (interquartile range) number of outpatient and inpatient stays per patient was 160 (19–364). Conclusion Our results demonstrated that data from the French national health care system can be integrated into the OMOP CDM. One of the main challenges was the use of international OMOP concepts to annotate data recorded in a French context. The use of local terminologies was an obstacle to conceptual mapping; with the exception of an adaptation of the International Classification of Diseases 10th Revision, the French health care system does not use international terminologies. It would be interesting to extend our present findings to the 65 million people registered in the French health care system.
      Citation: Appl Clin Inform 2020; 11: 013-022
      PubDate: 2020-01-08T00:00:00+0100
      DOI: 10.1055/s-0039-3402754
      Issue No: Vol. 11, No. 01 (2020)
  • Igniting Harmonized Digital Clinical Quality Measurement through
           Terminology, CQL, and FHIR
    • Authors: McClure; Robert C., Macumber, Caroline L., Skapik, Julia L., Smith, Anne Marie
      Pages: 023 - 033
      Abstract: Background Electronic clinical quality measures (eCQMs) seek to quantify the adherence of health care to evidence-based standards. This requires a high level of consistency to reduce the effort of data collection and ensure comparisons are valid. Yet, there is considerable variability in local data capture, in the use of data standards and in implemented documentation processes, so organizations struggle to implement quality measures and extract data reliably for comparison across patients, providers, and systems. Objective In this paper, we discuss opportunities for harmonization within and across eCQMs; specifically, at the level of the measure concept, the logical clauses or phrases, the data elements, and the codes and value sets. Methods The authors, experts in measure development, quality assurance, standards and implementation, reviewed measure structure and content to describe the state of the art for measure analysis and harmonization. Our review resulted in the identification of four measure component levels for harmonization. We provide examples for harmonization of each of the four measure components based on experience with current quality measurement programs including the Centers for Medicare and Medicaid Services eCQM programs. Results In general, there are significant issues with lack of harmonization across measure concepts, logical phrases, and data elements. This magnifies implementation problems, confuses users, and requires more elaborate data mapping and maintenance. Conclusion Comparisons using semantically equivalent data are needed to accurately measure performance and reduce workflow interruptions with the aim of reducing evidence-based care gaps. It comes as no surprise that electronic health record designed for purposes other than quality improvement and used within a fragmented care delivery system would benefit greatly from common data representation, measure harmony, and consistency. We suggest that by enabling measure authors and implementers to deliver consistent electronic quality measure content in four key areas; the industry can improve quality measurement.
      Citation: Appl Clin Inform 2020; 11: 023-033
      PubDate: 2020-01-08T00:00:00+0100
      DOI: 10.1055/s-0039-3402755
      Issue No: Vol. 11, No. 01 (2020)
  • Use, Perceived Usability, and Barriers to Implementation of a Patient
           Safety Dashboard Integrated within a Vendor EHR
    • Authors: Bersani; Kerrin, Fuller, Theresa E., Garabedian, Pamela, Espares, Jenzel, Mlaver, Eli, Businger, Alexandra, Chang, Frank, Boxer, Robert B., Schnock, Kumiko O., Rozenblum, Ronen, Dykes, Patricia C., Dalal, Anuj K., Benneyan, James C., Lehmann, Lisa S., Gershanik, Esteban F., Bates, David W., Schnipper, Jeffrey L.
      Pages: 034 - 045
      Abstract: Background Preventable adverse events continue to be a threat to hospitalized patients. Clinical decision support in the form of dashboards may improve compliance with evidence-based safety practices. However, limited research describes providers' experiences with dashboards integrated into vendor electronic health record (EHR) systems. Objective This study was aimed to describe providers' use and perceived usability of the Patient Safety Dashboard and discuss barriers and facilitators to implementation. Methods The Patient Safety Dashboard was implemented in a cluster-randomized stepped wedge trial on 12 units in neurology, oncology, and general medicine services over an 18-month period. Use of the Dashboard was tracked during the implementation period and analyzed in-depth for two 1-week periods to gather a detailed representation of use. Providers' perceptions of tool usability were measured using the Health Information Technology Usability Evaluation Scale (rated 1–5). Research assistants conducted field observations throughout the duration of the study to describe use and provide insight into tool adoption. Results The Dashboard was used 70% of days the tool was available, with use varying by role, service, and time of day. On general medicine units, nurses logged in throughout the day, with many logins occurring during morning rounds, when not rounding with the care team. Prescribers logged in typically before and after morning rounds. On neurology units, physician assistants accounted for most logins, accessing the Dashboard during daily brief interdisciplinary rounding sessions. Use on oncology units was rare. Satisfaction with the tool was highest for perceived ease of use, with attendings giving the highest rating (4.23). The overall lowest rating was for quality of work life, with nurses rating the tool lowest (2.88). Conclusion This mixed methods analysis provides insight into the use and usability of a dashboard tool integrated within a vendor EHR and can guide future improvements and more successful implementation of these types of tools.
      Citation: Appl Clin Inform 2020; 11: 034-045
      PubDate: 2020-01-15T00:00:00+0100
      DOI: 10.1055/s-0039-3402756
      Issue No: Vol. 11, No. 01 (2020)
  • Reducing Interruptive Alert Burden Using Quality Improvement Methodology
    • Authors: Chaparro; Juan D., Hussain, Cory, Lee, Jennifer A., Hehmeyer, Jessica, Nguyen, Manjusri, Hoffman, Jeffrey
      Pages: 046 - 058
      Abstract: Background Increased adoption of electronic health records (EHR) with integrated clinical decision support (CDS) systems has reduced some sources of error but has led to unintended consequences including alert fatigue. The “pop-up” or interruptive alert is often employed as it requires providers to acknowledge receipt of an alert by taking an action despite the potential negative effects of workflow interruption. We noted a persistent upward trend of interruptive alerts at our institution and increasing requests for new interruptive alerts. Objectives Using Institute for Healthcare Improvement (IHI) quality improvement (QI) methodology, the primary objective was to reduce the total volume of interruptive alerts received by providers. Methods We created an interactive dashboard for baseline alert data and to monitor frequency and outcomes of alerts as well as to prioritize interventions. A key driver diagram was developed with a specific aim to decrease the number of interruptive alerts from a baseline of 7,250 to 4,700 per week (35%) over 6 months. Interventions focused on the following key drivers: appropriate alert display within workflow, clear alert content, alert governance and standardization, user feedback regarding overrides, and respect for user knowledge. Results A total of 25 unique alerts accounted for 90% of the total interruptive alert volume. By focusing on these 25 alerts, we reduced interruptive alerts from 7,250 to 4,400 per week. Conclusion Systematic and structured improvements to interruptive alerts can lead to overall reduced interruptive alert burden. Using QI methods to prioritize our interventions allowed us to maximize our impact. Further evaluation should be done on the effects of reduced interruptive alerts on patient care outcomes, usability heuristics on cognitive burden, and direct feedback mechanisms on alert utility.
      Citation: Appl Clin Inform 2020; 11: 046-058
      PubDate: 2020-01-15T00:00:00+0100
      DOI: 10.1055/s-0039-3402757
      Issue No: Vol. 11, No. 01 (2020)
  • Application Programming Interfaces in Health Care: Findings from a
           Current-State Sociotechnical Assessment
    • Authors: Dullabh; Prashila, Hovey, Lauren, Heaney-Huls, Krysta, Rajendran, Nithya, Wright, Adam, Sittig, Dean F.
      Pages: 059 - 069
      Abstract: Objective Interest in application programming interfaces (APIs) is increasing as key stakeholders look for technical solutions to interoperability challenges. We explored three thematic areas to assess the current state of API use for data access and exchange in health care: (1) API use cases and standards; (2) challenges and facilitators for read and write capabilities; and (3) outlook for development of write capabilities. Methods We employed four methods: (1) literature review; (2) expert interviews with 13 API stakeholders; (3) review of electronic health record (EHR) app galleries; and (4) a technical expert panel. We used an eight-dimension sociotechnical model to organize our findings. Results The API ecosystem is complicated and cuts across five of the eight sociotechnical model dimensions: (1) app marketplaces support a range of use cases, the majority of which target providers' needs, with far fewer supporting patient access to data; (2) current focus on read APIs with limited use of write APIs; (3) where standards are used, they are largely Fast Healthcare Interoperability Resources (FHIR); (4) FHIR-based APIs support exchange of electronic health information within the common clinical data set; and (5) validating external data and data sources for clinical decision making creates challenges to provider workflows. Conclusion While the use of APIs in health care is increasing rapidly, it is still in the pilot stages. We identified five key issues with implications for the continued advancement of API use: (1) a robust normative FHIR standard; (2) expansion of the common clinical data set to other data elements; (3) enhanced support for write implementation; (4) data provenance rules; and (5) data governance rules. Thus, while APIs are being touted as a solution to interoperability challenges, they remain an emerging technology that is only one piece of a multipronged approach to data access and use.
      Citation: Appl Clin Inform 2020; 11: 059-069
      PubDate: 2020-01-22T00:00:00+0100
      DOI: 10.1055/s-0039-1701001
      Issue No: Vol. 11, No. 01 (2020)
  • Self-Management Behaviors of Patients with Type 1 Diabetes: Comparing Two
           Sources of Patient-Generated Data
    • Authors: Karway; George, Grando, Maria Adela, Grimm, Kevin, Groat, Danielle, Cook, Curtiss, Thompson, Bithika
      Pages: 070 - 078
      Abstract: Objectives This article aims to evaluate adult type 1 diabetes mellitus (T1DM) self-management behaviors (SMBs) related to exercise and alcohol on a survey versus a smartphone app to compare self-reported and self-tracked SMBs, and examine inter- and intrapatient variability. Methods Adults with T1DM on insulin pump therapy were surveyed about their alcohol, meal, and exercise SMBs. For 4 weeks, participants self-tracked their alcohol, meal, and exercise events, and their SMBs corresponding with these events via an investigator-developed app. Descriptive statistics and generalized linear mixed-effect models were used to analyze the data Results Thirty-five participants self-tracked over 5,000 interactions using the app. Variability in how participants perceived the effects of exercise and alcohol on their blood glucose was observed. The congruity between SMBs self-reported on the survey and those self-tracked with the app was measured as mean (SD). The lowest congruity was for alcohol and exercise with 61.9% (22.7) and 66.4% (20.2), respectively. Congruity was higher for meals with 80.9% (21.0). There was significant daily intra- and interpatient variability in SMBs related to preprandial bolusing: recommended bolus, p 
      Citation: Appl Clin Inform 2020; 11: 070-078
      PubDate: 2020-01-22T00:00:00+0100
      DOI: 10.1055/s-0039-1701002
      Issue No: Vol. 11, No. 01 (2020)
  • Detection and Remediation of Misidentification Errors in Radiology
           Examination Ordering
    • Authors: Sheehan; Scott E., Safdar, Nasia, Singh, Hardeep, Sittig, Dean F., Bruno, Michael A., Keller, Kelli, Kinnard, Samantha, Brunner, Michael C.
      Pages: 079 - 087
      Abstract: Background Despite progress in patient safety, misidentification errors in radiology such as ordering imaging on the wrong anatomic side persist. If undetected, these errors can cause patient harm for multiple reasons, in addition to producing erroneous electronic health records (EHR) data. Objectives We describe the pilot testing of a quality improvement methodology using electronic trigger tools and preimaging checklists to detect “wrong-side” misidentification errors in radiology examination ordering, and to measure staff adherence to departmental policy in error remediation. Methods We retrospectively applied and compared two methods for the detection of “wrong-side” misidentification errors among a cohort of all imaging studies ordered during a 1-year period (June 1, 2015–May 31, 2016) at our tertiary care hospital. Our methods included: (1) manual review of internal quality improvement spreadsheet records arising from the prospective performance of preimaging safety checklists, and (2) automated error detection via the development and validation of an electronic trigger tool which identified discrepant side indications within EHR imaging orders. Results Our combined methods detected misidentification errors in 6.5/1,000 of study cohort imaging orders. Our trigger tool retrospectively identified substantially more misidentification errors than were detected prospectively during preimaging checklist performance, with a high positive predictive value (PPV: 88.4%, 95% confidence interval: 85.4–91.4). However, two third of errors detected during checklist performance were not detected by the trigger tool, and checklist-detected errors were more often appropriately resolved (p 
      Citation: Appl Clin Inform 2020; 11: 079-087
      PubDate: 2020-01-29T00:00:00+0100
      DOI: 10.1055/s-0039-3402730
      Issue No: Vol. 11, No. 01 (2020)
  • Evaluating Usability of a Touchless Image Viewer in the Operating Room
    • Authors: Bockhacker; Markus, Syrek, Hannah, Elstermann von Elster, Max, Schmitt, Sebastian, Roehl, Henning
      Pages: 088 - 094
      Abstract: Background Availability of patient-specific image data, gathered from preoperatively conducted studies, like computed tomography scans and magnetic resonance imaging studies, during a surgical procedure is a key factor for surgical success and patient safety. Several alternative input methods, including recognition of hand gestures, have been proposed for surgeons to interact with medical image viewers during an operation. Previous studies pointed out the need for usability evaluation of these systems. Objectives We describe the accuracy and usability of a novel software system, which integrates gesture recognition via machine learning into an established image viewer. Methods This pilot study is a prospective, observational trial, which asked surgeons to interact with software to perform two standardized tasks in a sterile environment, modeled closely to a real-life situation in an operating room. To assess usability, the validated “System Usability Scale” (SUS) was used. On a technical level, we also evaluated the accuracy of the underlying neural network. Results The neural network reached 98.94% accuracy while predicting the gestures during validation. Eight surgeons with an average of 6.5 years of experience participated in the usability study. The system was rated on average with 80.25 points on the SUS. Conclusion The system showed good overall usability; however, additional areas of potential improvement were identified and further usability studies are needed. Because the system uses standard PC hardware, it made for easy integration into the operating room.
      Citation: Appl Clin Inform 2020; 11: 088-094
      PubDate: 2020-01-29T00:00:00+0100
      DOI: 10.1055/s-0039-1701003
      Issue No: Vol. 11, No. 01 (2020)
  • The Financial and Clinical Impact of an Electronic Health Record
           Integrated Pathway in Elective Colon Surgery
    • Authors: Austrian; Jonathan S., Volpicelli, Frank, Jones, Simon, Bernstein, Mitchell A., Padikkala, Jane, Bagheri, Ashley, Blecker, Saul
      Pages: 095 - 103
      Abstract: Background Enhanced Recovery after Surgery (ERAS) pathways have been shown to reduce length of stay, but there have been limited evaluations of novel electronic health record (EHR)-based pathways. Compliance with ERAS in real-world settings has been problematic. Objective This article evaluates a novel ERAS electronic pathway (E-Pathway) activity integrated with the EHR for patients undergoing elective colorectal surgery. Methods We performed a retrospective cohort study of surgical patients age ≥ 18 years hospitalized from March 1, 2013 to August 31, 2016. The primary cohort consisted of patients admitted for elective colon surgery. We also studied a control group of patients undergoing other elective procedures. The E-Pathway was implemented on March 2, 2015. The primary outcome was variable costs per case. Secondary outcomes were observed to expected length of stay and 30-day readmissions. Results We included 823 (470 and 353 in the pre- and postintervention, respectively) colon surgery patients and 3,415 (1,819 and 1,596 in the pre- and postintervention) surgical control patients in the study. Among the colon surgery cohort, there was statistically significant (p = 0.040) decrease in costs of 1.28% (95% confidence interval [CI] 0.06–2.48%) per surgical encounter per month over the 18-month postintervention period, amounting to a total savings of $2,730 per patient at the 1-year postintervention period. The surgical control group had a nonsignificant (p = 0.231) decrease in monthly costs of 0.57% (95% CI 1.51 to – 0.37%) postintervention. For the 30-day readmission rates, there were no statistically significant changes in either cohort. Conclusion Our study is the first to report on the reduced costs after implementation of a novel sophisticated E-Pathway for ERAS. E-Pathways can be a powerful vehicle to support ERAS adoption.
      Citation: Appl Clin Inform 2020; 11: 095-103
      PubDate: 2020-02-05T00:00:00+0100
      DOI: 10.1055/s-0039-1701004
      Issue No: Vol. 11, No. 01 (2020)
  • The Successful Usage of the DICOM Images Exchange System (ePACS) in the
           Czech Republic
    • Authors: Bruthans; Jan
      Pages: 104 - 111
      Abstract: Background The picture archiving and communication system (PACS) has already replaced classic hard copy film technology. With new functions of PACS under consideration, attention turns to the sharing of medical images between different institutions. The Czech Republic is one of the few countries using a nation-wide medical images exchange system known as ePACS. It is based on dedicated hardware and one central router, although theoretical models tend to prefer cloud-based sharing. Objective Despite its simple design and lack of advanced features, this system has successively evolved into a widely used tool. The aim of this article is to offer an overview of its use and functions and to show that even a simple system can be widely used. Methods Using data from the producer of ePACS (the ICZ company) and from other sources, the system was described and data about its performance have been obtained. Results Every acute-care hospital (140) and about a quarter of outpatient facilities (105) in the Czech Republic are now equipped with ePACS and are therefore able to share medical images. The number of studies transmitted rises every year, from 12,000 in 2008 to more than 640,000 in 2018, which is approximately 4% of all studies produced. The system was primarily designed and is used to share images between acute-care hospitals but a very special usage has also evolved, as it is employed in a teleradiology service with private enterprises too. Conclusion ePACS is expanding in the Czech Republic despite having only limited functions and despite its principle that simply copies a classic workflow when sending studies on Compact Discs. Although other systems for image sharing might be more advanced, ePACS brings to the Czech health care system the capability to exchange medical images on a national level.
      Citation: Appl Clin Inform 2020; 11: 104-111
      PubDate: 2020-02-05T00:00:00+0100
      DOI: 10.1055/s-0040-1701252
      Issue No: Vol. 11, No. 01 (2020)
  • To Share is Human! Advancing Evidence into Practice through a National
           Repository of Interoperable Clinical Decision Support
    • Authors: Lomotan; Edwin A., Meadows, Ginny, Michaels, Maria, Michel, Jeremy J., Miller, Kristen
      Pages: 112 - 121
      Abstract: Background Healthcare systems devote substantial resources to the development of clinical decision support (CDS) largely independently. The process of translating evidence-based practice into useful and effective CDS may be more efficient and less duplicative if healthcare systems shared knowledge about the translation, including workflow considerations, key assumptions made during the translation process, and technical details. Objective Describe how a national repository of CDS can serve as a public resource for healthcare systems, academic researchers, and informaticists seeking to share and reuse CDS knowledge resources or “artifacts.” Methods In 2016, the Agency for Healthcare Research and Quality (AHRQ) launched CDS Connect as a public, web-based platform for authoring and sharing CDS knowledge artifacts. Researchers evaluated early use and impact of the platform by collecting user experiences of AHRQ-sponsored and community-led dissemination efforts and through quantitative/qualitative analysis of site metrics. Efforts are ongoing to quantify efficiencies gained by healthcare systems that leverage shared, interoperable CDS artifacts rather than developing similar CDS de novo and in isolation. Results Federal agencies, academic institutions, and others have contributed over 50 entries to CDS Connect for sharing and dissemination. Analysis indicates shareable CDS resources reduce team sizes and the number of tasks and time required to design, develop, and deploy CDS. However, the platform needs further optimization to address sociotechnical challenges. Benefits of sharing include inspiring others to undertake similar CDS projects, identifying external collaborators, and improving CDS artifacts as a result of feedback. Organizations are adapting content available through the platform for continued research, innovation, and local implementations. Conclusion CDS Connect has provided a functional platform where CDS developers are actively sharing their work. CDS sharing may lead to improved implementation efficiency through numerous pathways, and further research is ongoing to quantify efficiencies gained.
      Citation: Appl Clin Inform 2020; 11: 112-121
      PubDate: 2020-02-12T00:00:00+0100
      DOI: 10.1055/s-0040-1701253
      Issue No: Vol. 11, No. 01 (2020)
  • Experiences of Health Care Providers Using a Mobile Medical Photography
    • Authors: Wyatt; Kirk D., Willaert, Brian N., Lohse, Christine M., Pallagi, Peter J., Yiannias, James A., Hellmich, Thomas R.
      Pages: 122 - 129
      Abstract: Objective To understand the ways in which providers use a mobile photography application integrated with the electronic health record (EHR) to facilitate clinical care, and the process outcomes that result from the application's use. Methods An e-mail survey was sent on November 13, 2017, to 1,463 health care providers at Mayo Clinic who had used an internally developed, EHR-integrated medical photography application. Results The survey was completed by 712 (49%) providers. Providers reported using the application on approximately 1 in 7 days spent in clinical practice. Median provider satisfaction with the use of the application (0–100 scale; higher numbers indicate favorable response) was 94 (interquartile range [IQR]: 74–100). Although the use for store-and-forward telemedicine was reported (22% often or frequently used the application to send photographs to a specialist for advice), the most common use was for clinical documentation (65% often or frequently used the application to supplement text-based notes with photographs, and 71% often or frequently used the application to take photographs for reference by a colleague who may see the patient in the future). Of the health care providers, 36% indicated that the application's use often or frequently expedited treatment. Discussion Health care providers reported using a mobile point-of-care medical photography application regularly in clinical practice and were generally satisfied with the application. Conclusion Point-of-care medical photography using a secure mobile, EHR-integrated application has potential to become a new standard of care for clinical documentation and may facilitate continuity across the continuum of care with multiple providers who see a patient.
      Citation: Appl Clin Inform 2020; 11: 122-129
      PubDate: 2020-02-12T00:00:00+0100
      DOI: 10.1055/s-0040-1701254
      Issue No: Vol. 11, No. 01 (2020)
  • Promoting Quality Face-to-Face Communication during Ophthalmology
           Encounters in the Electronic Health Record Era
    • Authors: Baxter; Sally L., Gali, Helena E., Chiang, Michael F., Hribar, Michelle R., Ohno-Machado, Lucila, El-Kareh, Robert, Huang, Abigail E., Chen, Heather E., Camp, Andrew S., Kikkawa, Don O., Korn, Bobby S., Lee, Jeffrey E., Longhurst, Christopher A., Millen, Marlene
      Pages: 130 - 141
      Abstract: Objective To evaluate informatics-enabled quality improvement (QI) strategies for promoting time spent on face-to-face communication between ophthalmologists and patients. Methods This prospective study involved deploying QI strategies during implementation of an enterprise-wide vendor electronic health record (EHR) in an outpatient academic ophthalmology department. Strategies included developing single sign-on capabilities, activating mobile- and tablet-based applications, EHR personalization training, creating novel workflows for team-based orders, and promoting problem-based charting to reduce documentation burden. Timing data were collected during 648 outpatient encounters. Outcomes included total time spent by the attending ophthalmologist on the patient, time spent on documentation, time spent on examination, and time spent talking with the patient. Metrics related to documentation efficiency, use of personalization features, use of team-based orders, and note length were also measured from the EHR efficiency portal and compared with averages for ophthalmologists nationwide using the same EHR. Results Time spent on exclusive face-to-face communication with patients initially decreased with EHR implementation (2.9 to 2.3 minutes, p = 0.005) but returned to the paper baseline by 6 months (2.8 minutes, p = 0.99). Observed participants outperformed national averages of ophthalmologists using the same vendor system on documentation time per appointment, number of customized note templates, number of customized order lists, utilization of team-based orders, note length, and time spent after-hours on EHR use. Conclusion Informatics-enabled QI interventions can promote patient-centeredness and face-to-face communication in high-volume outpatient ophthalmology encounters. By employing an array of interventions, time spent exclusively talking with the patient returned to levels equivalent to paper charts by 6 months after EHR implementation. This was achieved without requiring EHR redesign, use of scribes, or excessive after-hours work. Documentation efficiency can be achieved using interventions promoting personalization and team-based workflows. Given their efficacy in preserving face-to-face physician–patient interactions, these strategies may help alleviate risk of physician burnout.
      Citation: Appl Clin Inform 2020; 11: 130-141
      PubDate: 2020-02-19T00:00:00+0100
      DOI: 10.1055/s-0040-1701255
      Issue No: Vol. 11, No. 01 (2020)
  • Joint Design with Providers of Clinical Decision Support for Value-Based
           Advanced Shoulder Imaging
    • Authors: Brunner; Michael C., Sheehan, Scott E., Yanke, Eric M., Sittig, Dean F., Safdar, Nasia, Hill, Barbara, Lee, Kenneth S., Orwin, John F., Vanness, David J., Hildebrand, Christopher J., Bruno, Michael A., Erickson, Timothy J., Zea, Ryan, Moberg, D. Paul
      Pages: 142 - 152
      Abstract: Background Provider orders for inappropriate advanced imaging, while rarely altering patient management, contribute enough to the strain on available health care resources, and therefore the United States Congress established the Appropriate Use Criteria Program. Objectives To examine whether co-designing clinical decision support (CDS) with referring providers will reduce barriers to adoption and facilitate more appropriate shoulder ultrasound (US) over magnetic resonance imaging (MRI) in diagnosing Veteran shoulder pain, given similar efficacies and only 5% MRI follow-up rate after shoulder US. Methods We used a theory-driven, convergent parallel mixed-methods approach to prospectively (1) determine medical providers' reasons for selecting MRI over US in diagnosing shoulder pain and identify barriers to ordering US, (2) co-design CDS, informed by provider interviews, to prompt appropriate US use, and (3) assess CDS impact on shoulder imaging use. CDS effectiveness in guiding appropriate shoulder imaging was evaluated through monthly monitoring of ordering data at our quaternary care Veterans Hospital. Key outcome measures were appropriate MRI/US use rates and transition to ordering US by both musculoskeletal specialist and generalist providers. We assessed differences in ordering using a generalized estimating equations logistic regression model. We compared continuous measures using mixed effects analysis of variance with log-transformed data. Results During December 2016 to March 2018, 569 (395 MRI, 174 US) shoulder advanced imaging examinations were ordered by 111 providers. CDS “co-designed” in collaboration with providers increased US from 17% (58/335) to 50% (116/234) of all orders (p 
      Citation: Appl Clin Inform 2020; 11: 142-152
      PubDate: 2020-02-19T00:00:00+0100
      DOI: 10.1055/s-0040-1701256
      Issue No: Vol. 11, No. 01 (2020)
  • Differences, Opportunities, and Strategies in Drug Alert
           Optimization—Experiences of Two Different Integrated Health Care Systems
    • Authors: Saiyed; Salim M., Davis, Katherine R., Kaelber, David C.
      Pages: 777 - 782
      Abstract: Background Concerns about the number of automated medication alerts issued within the electronic health record (EHR), and the subsequent potential for alarm fatigue, led us to examine strategies and methods to optimize the configuration of our drug alerts. Objectives This article reports on comprehensive drug alerting rates and develops strategies across two different health care systems to reduce the number of drug alerts. Methods Standardized reports compared drug alert rates between the two systems, among 13 categories of drug alerts. Both health care systems made modifications to the out-of-box alerts available from their EHR and drug information vendors, focusing on system-wide approaches, when relevant, while performing more drug-specific changes when necessary. Results Drug alerting rates even after initial optimization were 38 alerts and 51 alerts per 100 drug orders, respectively. Eight principles were identified and developed to reflect the themes in the implementation and optimization of drug alerting. Conclusion A team-based, systematic approach to optimizing drug-alerting strategies can reduce the number of drug alerts, but alert rates still remain high. In addition to strategic principles, additional tactical guidelines and recommendations need to be developed to enhance out-of-the-box clinical decision support for drug alerts.
      Citation: Appl Clin Inform 2019; 10: 777-782
      PubDate: 2019-10-16T00:00:00+01:00
      DOI: 10.1055/s-0039-1697596
      Issue No: Vol. 10, No. 05 (2019)
  • A Clinically Integrated mHealth App and Practice Model for Collecting
           Patient-Reported Outcomes between Visits for Asthma Patients:
           Implementation and Feasibility
    • Authors: Rudin; Robert S., Fanta, Christopher H., Qureshi, Nabeel, Duffy, Erin, Edelen, Maria O., Dalal, Anuj K., Bates, David W.
      Pages: 783 - 793
      Abstract: Objective Mobile health (mHealth) apps may prove to be useful tools for supporting chronic disease management. We assessed the feasibility of implementing a clinically integrated mHealth app and practice model to facilitate between-visit asthma symptom monitoring as per guidelines and with the help of patient-reported outcomes (PRO). Methods We implemented the intervention at two pulmonary clinics and conducted a mixed-methods analysis of app usage data and semi-structured interview of patients and clinician participants over a 25-week study period. Results Five physicians, 1 physician's assistant, 1 nurse, and 26 patients participated. Twenty-four patients (92%) were still participating in the intervention at the end of the 25-week study period. On average, each patient participant completed 21 of 25 questionnaires (84% completion rate). Weekly completion rates were higher for participants who were female (88 vs. 73%, p = 0.02) and obtained a bachelor's degree level or higher (94 vs. 74%, p = 0.04). On average, of all questionnaires, including both completed and not completed (25 weekly questionnaires times 26 patient participants), 25% had results severe enough to qualify for a callback from a nurse; however, patients declined this option in roughly half of the cases in which they were offered the option. We identified 6 key themes from an analysis of 21 patients and 5 clinician interviews. From the patient's perspective, these include more awareness of asthma, more connected with provider, and app simplicity. From the clinician's perspective, these include minimal additional work required, facilitating triage, and informing conversations during visits. Conclusion Implementation of a clinically integrated mHealth app and practice model can achieve high patient retention and adherence to guideline-recommended asthma symptom monitoring, while minimally burdening clinicians. The intervention has the potential for scaling to primary care and reducing utilization of urgent and emergency care.
      Citation: Appl Clin Inform 2019; 10: 783-793
      PubDate: 2019-10-16T00:00:00+01:00
      DOI: 10.1055/s-0039-1697597
      Issue No: Vol. 10, No. 05 (2019)
  • Incrementally Transforming Electronic Medical Records into the
           Observational Medical Outcomes Partnership Common Data Model: A
           Multidimensional Quality Assurance Approach
    • Authors: Lynch; Kristine E., Deppen, Stephen A., DuVall, Scott L., Viernes, Benjamin, Cao, Aize, Park, Daniel, Hanchrow, Elizabeth, Hewa, Kushan, Greaves, Peter, Matheny, Michael E.
      Pages: 794 - 803
      Abstract: Background The development and adoption of health care common data models (CDMs) has addressed some of the logistical challenges of performing research on data generated from disparate health care systems by standardizing data representations and leveraging standardized terminology to express clinical information consistently. However, transforming a data system into a CDM is not a trivial task, and maintaining an operational, enterprise capable CDM that is incrementally updated within a data warehouse is challenging. Objectives To develop a quality assurance (QA) process and code base to accompany our incremental transformation of the Department of Veterans Affairs Corporate Data Warehouse health care database into the Observational Medical Outcomes Partnership (OMOP) CDM to prevent incremental load errors. Methods We designed and implemented a multistage QA) approach centered on completeness, value conformance, and relational conformance data-quality elements. For each element we describe key incremental load challenges, our extract, transform, and load (ETL) solution of data to overcome those challenges, and potential impacts of incremental load failure. Results Completeness and value conformance data-quality elements are most affected by incremental changes to the CDW, while updates to source identifiers impact relational conformance. ETL failures surrounding these elements lead to incomplete and inaccurate capture of clinical concepts as well as data fragmentation across patients, providers, and locations. Conclusion Development of robust QA processes supporting accurate transformation of OMOP and other CDMs from source data is still in evolution, and opportunities exist to extend the existing QA framework and tools used for incremental ETL QA processes.
      Citation: Appl Clin Inform 2019; 10: 794-803
      PubDate: 2019-10-23T00:00:00+01:00
      DOI: 10.1055/s-0039-1697598
      Issue No: Vol. 10, No. 05 (2019)
  • A Comparison of One- and Four-Open-Chart Access: No Change in Computerized
           Provider Order Entry Error Rates
    • Authors: Scariati; Paula, Knapp, Herschel, Gray, Stuart
      Pages: 804 - 809
      Abstract: Objective To assess changes in computerized provider order entry error rates among providers who with less than 24-hour notice were switched from four-chart access to one-chart-only access. Methods An interrupted time series analysis of emergency medicine providers, hospitalists, and maternal child health providers was performed with pairwise comparison of computerized provider order entry error rates within and between specialties. This retrospective snapshot consisted of four phases. Phase 1 was the baseline 2 weeks where providers were privileged to work with up to four charts open. Phase 2 was the 2-week period where providers were limited to one-chart access. Phase 3 was the 2-week period where providers were returned to four-chart access. And phase 4 was a 2-week period 3 months following the end of phase 3. Results Analysis of the overall and specialty-stratified cohorts revealed no statistically significant differences in median computerized provider order entry error rates across the four phases (Wilcoxon signed-rank test, α = 0.05). However, statistically significant differences in median computerized provider order entry error rates were detected between the three specialties within each phase of the study (Kruskal–Wallis, p 
      Citation: Appl Clin Inform 2019; 10: 804-809
      PubDate: 2019-10-23T00:00:00+01:00
      DOI: 10.1055/s-0039-1697599
      Issue No: Vol. 10, No. 05 (2019)
  • Towards a Maturity Model for Clinical Decision Support Operations
    • Authors: Orenstein; Evan W., Muthu, Naveen, Weitkamp, Asli O., Ferro, Daria F., Zeidlhack, Mike D., Slagle, Jason, Shelov, Eric, Tobias, Marc C.
      Pages: 810 - 819
      Abstract: Clinical decision support (CDS) systems delivered through the electronic health record are an important element of quality and safety initiatives within a health care system. However, managing a large CDS knowledge base can be an overwhelming task for informatics teams. Additionally, it can be difficult for these informatics teams to communicate their goals with external operational stakeholders and define concrete steps for improvement. We aimed to develop a maturity model that describes a roadmap toward organizational functions and processes that help health care systems use CDS more effectively to drive better outcomes. We developed a maturity model for CDS operations through discussions with health care leaders at 80 organizations, iterative model development by four clinical informaticists, and subsequent review with 19 health care organizations. We ceased iterations when feedback from three organizations did not result in any changes to the model. The proposed CDS maturity model includes three main “pillars”: “Content Creation,” “Analytics and Reporting,” and “Governance and Management.” Each pillar contains five levels—advancing along each pillar provides CDS teams a deeper understanding of the processes CDS systems are intended to improve. A “roof” represents the CDS functions that become attainable after advancing along each of the pillars. Organizations are not required to advance in order and can develop in one pillar separately from another. However, we hypothesize that optimal deployment of preceding levels and advancing in tandem along the pillars increase the value of organizational investment in higher levels of CDS maturity. In addition to describing the maturity model and its development, we also provide three case studies of health care organizations using the model for self-assessment and determine next steps in CDS development.
      Citation: Appl Clin Inform 2019; 10: 810-819
      PubDate: 2019-10-30T00:00:00+0100
      DOI: 10.1055/s-0039-1697905
      Issue No: Vol. 10, No. 05 (2019)
  • The Determinants of M-Health Adoption in Developing Countries: An
           Empirical Investigation
    • Authors: Alaiad; Ahmad, Alsharo, Mohammad, Alnsour, Yazan
      Pages: 820 - 840
      Abstract: Background The potential benefit of mobile health (M-Health) in developing countries for improving the efficiency of health care service delivery, health care quality, and patient safety, as well as reducing cost, has been increasingly recognized and emphasized in the last few years. Objective Limited research has investigated the facilitators and barriers for the adoption of M-Health in developing countries to secure successful implementation of the technology. To fill this knowledge gap, we propose an integrative model that explains the patient's adoption behavior of M-Health in developing countries grounded on the unified theory of acceptance and use of technology, dual-factor model, and health belief model. Method We empirically tested and evaluated the model based on data collected using a survey method from 280 patients living in a developing country. Partial least squares (PLS-SEM) technique was used for data analysis. Results The results showed that performance expectancy, effort expectancy, social influence, perceived health threat, M-Health app quality, and life quality expectancy have a direct positive effect on patients’ intention to use M-Health. The results also showed that security and privacy risks have a direct negative effect on the patient's intention to use M-Health. However, resistance to change was found to have an indirect negative effect on patients’ intention to use M-Health through the performance expectancy. Conclusion The research contributes to the existing literature of health information systems and M-Health by better understanding how technological, social, and functional factors are associated with digital health applications and services use and success in the context of developing countries. With the widespread availability of mobile technologies and services and the growing demand for M-Health apps, this research can help guide the development of the next generation of M-Health apps with a focus on the needs of patients in developing countries. The research has several theoretical and practical implications for the health care industry, government, policy makers, and technology developers and designers.
      Citation: Appl Clin Inform 2019; 10: 820-840
      PubDate: 2019-10-30T00:00:00+0100
      DOI: 10.1055/s-0039-1697906
      Issue No: Vol. 10, No. 05 (2019)
  • Patients as Agents in Behavioral Health Research and Service Provision:
           Recommendations to Support the Learning Health System
    • Authors: Galvin; Hannah K., Petersen, Carolyn, Subbian, Vignesh, Solomonides, Anthony
      Pages: 841 - 848
      Abstract: Authentic inclusion and engagement of behavioral health patients in their care delivery and in the process of scientific discovery are often challenged in the health care system. Consequently, there is a growing need to engage with and better serve the needs of behavioral health patients, particularly by leveraging health information technologies. In this work, we present rationale and strategies for improving patient engagement in this population in research and clinical care. First, we describe the potential for creating meaningful patient–investigator partnerships in behavioral health research to allow for cocreation of knowledge with patients. Second, in the context of behavioral health services, we explore the utility of sharing clinical notes to promote patients' agency in care delivery. Both lines of inquiry are centered in a Learning Health System model for behavioral health, where patients are agents in enhancing the therapeutic alliance and advancing the process of knowledge generation. Recommendations include genuinely democratizing the health care system and biomedical research enterprise through patient-centered information technologies such as patient portals. In research and technology development, we recommend seeking and tailoring behavioral health patients' involvement to their abilities, promoting patient input in data analysis plans, evaluating research and informatics initiatives for patients and clinicians, and sharing success and research findings with patients. In clinical practice, we recommend encouraging patients to read behavioral health notes on portals, engaging in proactive communication regarding note content, assessing outcomes including stress and anxiety in response to note content, and working with technology providers to support note-sharing governance and deployment.
      Citation: Appl Clin Inform 2019; 10: 841-848
      PubDate: 2019-11-06T00:00:00+0100
      DOI: 10.1055/s-0039-1700536
      Issue No: Vol. 10, No. 05 (2019)
  • Neurological Dashboards and Consultation Turnaround Time at an Academic
           Medical Center
    • Authors: Kummer; Benjamin R., Willey, Joshua Z., Zelenetz, Michael J., Hu, Yiping, Sengupta, Soumitra, Elkind, Mitchell S. V., Hripcsak, George
      Pages: 849 - 858
      Abstract: Background Neurologists perform a significant amount of consultative work. Aggregative electronic health record (EHR) dashboards may help to reduce consultation turnaround time (TAT) which may reflect time spent interfacing with the EHR. Objectives This study was aimed to measure the difference in TAT before and after the implementation of a neurological dashboard. Methods We retrospectively studied a neurological dashboard in a read-only, web-based, clinical data review platform at an academic medical center that was separate from our institutional EHR. Using our EHR, we identified all distinct initial neurological consultations at our institution that were completed in the 5 months before, 5 months after, and 12 months after the dashboard go-live in December 2017. Using log data, we determined total dashboard users, unique page hits, patient-chart accesses, and user departments at 5 months after go-live. We calculated TAT as the difference in time between the placement of the consultation order and completion of the consultation note in the EHR. Results By April 30th in 2018, we identified 269 unique users, 684 dashboard page hits (median hits/user 1.0, interquartile range [IQR] = 1.0), and 510 unique patient-chart accesses. In 5 months before the go-live, 1,434 neurology consultations were completed with a median TAT of 2.0 hours (IQR = 2.5) which was significantly longer than during 5 months after the go-live, with 1,672 neurology consultations completed with a median TAT of 1.8 hours (IQR = 2.2; p = 0.001). Over the following 7 months, 2,160 consultations were completed and median TAT remained unchanged at 1.8 hours (IQR = 2.5). Conclusion At a large academic institution, we found a significant decrease in inpatient consult TAT 5 and 12 months after the implementation of a neurological dashboard. Further study is necessary to investigate the cognitive and operational effects of aggregative dashboards in neurology and to optimize their use.
      Citation: Appl Clin Inform 2019; 10: 849-858
      PubDate: 2019-11-06T00:00:00+0100
      DOI: 10.1055/s-0039-1698465
      Issue No: Vol. 10, No. 05 (2019)
  • Usability Testing of an Interactive Dashboard for Surgical Quality
           Improvement in a Large Congenital Heart Center
    • Authors: Wu; Danny T. Y., Vennemeyer, Scott, Brown, Kelly, Revalee, Jason, Murdock, Paul, Salomone, Sarah, France, Ashton, Clarke-Myers, Katherine, Hanke, Samuel P.
      Pages: 859 - 869
      Abstract: Background Interactive data visualization and dashboards can be an effective way to explore meaningful patterns in large clinical data sets and to inform quality improvement initiatives. However, these interactive dashboards may have usability issues that undermine their effectiveness. These usability issues can be attributed to mismatched mental models between the designers and the users. Unfortunately, very few evaluation studies in visual analytics have specifically examined such mismatches between these two groups. Objectives We aimed to evaluate the usability of an interactive surgical dashboard and to seek opportunities for improvement. We also aimed to provide empirical evidence to demonstrate the mismatched mental models between the designers and the users of the dashboard. Methods An interactive dashboard was developed in a large congenital heart center. This dashboard provides real-time, interactive access to clinical outcomes data for the surgical program. A mixed-method, two-phase study was conducted to collect user feedback. A group of designers (N = 3) and a purposeful sample of users (N = 12) were recruited. The qualitative data were analyzed thematically. The dashboards were compared using the System Usability Scale (SUS) and qualitative data. Results The participating users gave an average SUS score of 82.9 on the new dashboard and 63.5 on the existing dashboard (p = 0.006). The participants achieved high task accuracy when using the new dashboard. The qualitative analysis revealed three opportunities for improvement. The data analysis and triangulation provided empirical evidence to the mismatched mental models. Conclusion We conducted a mixed-method usability study on an interactive surgical dashboard and identified areas of improvements. Our study design can be an effective and efficient way to evaluate visual analytics systems in health care. We encourage researchers and practitioners to conduct user-centered evaluation and implement education plans to mitigate potential usability challenges and increase user satisfaction and adoption.
      Citation: Appl Clin Inform 2019; 10: 859-869
      PubDate: 2019-11-13T00:00:00+0100
      DOI: 10.1055/s-0039-1698466
      Issue No: Vol. 10, No. 05 (2019)
  • Enhancing Asthma Patients' Self-Management through Smartphone-Based
           Application: Design, Usability Evaluation, and Educational Intervention
    • Authors: Farzandipour; Mehrdad, Nabovati, Ehsan, Heidarzadeh Arani, Marzieh, Akbari, Hossein, Sharif, Reihane, Anvari, Shima
      Pages: 870 - 878
      Abstract: Objective The aim of this study was to design and evaluate a smartphone-based application for improving self-management in patients with asthma and evaluate its effects on their knowledge. Methods In this applied research, based on the Clinical Practice Guideline and a systematic review, a questionnaire was designed to determine the application information content and functionality requirements by 15 pediatric and adult asthma and allergy specialist. Then the application was designed and developed using Adobe Air software on the Android operating system. Usability evaluation of the mobile application was performed using the standard questionnaire for user interaction satisfaction (QUIS), which completed by 30 patients with asthma, 8 information technology (IT) specialists, and 2 asthma and allergy specialists. Self-management knowledge of 30 asthma patients was measured using a researcher-made questionnaire before and after using the application. Results The number of specialists in the both Delphi rounds was 15 and the mean work experiences were 17.6 years. The most important elements for asthma self-management were avoiding exposure to allergen and triggers (96%), drug treatment (94.6%), and how to use the therapeutic tools (92.4%), and the most important functionalities were alerting the patients when they did not control asthma (92%), setting reminders for timely drug use (85.4%) and therapeutic tools (82.6%), recording prescription drugs (82.6%), and peak flow meter values (82%). Usability evaluation showed that 30 patients with asthma, 8 IT specialists, and 2 physicians evaluated the application at a “good” level. The mean score of the patients' knowledge before intervention was 2.43 ± 0.95 which after intervention was significantly increased to 4.3 ± 0.56 (p 
      Citation: Appl Clin Inform 2019; 10: 870-878
      PubDate: 2019-11-13T00:00:00+0100
      DOI: 10.1055/s-0039-1700866
      Issue No: Vol. 10, No. 05 (2019)
  • Evaluating the Impact of a New Smartphone Texting Tool on Patient Care in
           Obstetrics, an Emergent Healthcare Setting
    • Authors: Feinberg; Jacqueline, Shaw, Sara, Kashyap, Nitu, Illuzzi, Jessica, Campbell, Katherine, Hsiao, Allen L., Pettker, Christian M.
      Pages: 879 - 887
      Abstract: Background Hospitals across the country are investing millions of dollars to adopt new Health Insurance Portability and Accountability Act (HIPAA)-compliant secure text messaging systems. However, in nearly all cases, these implementations are occurring without evaluation of their impact on patient care. Objective To evaluate perceived impact on patient care and workflow of new text messaging system implemented in obstetrics at Yale-New Haven Hospital and to inform guidelines for future implementations in emergent settings. Methods A new HIPAA-compliant texting system was implemented in obstetrics in 2016. Before implementation of the new system, residents and nurses were surveyed on perceived effect of communication system (pagers with text receiving, service mobile phones, personal cell phones) on clinical workflow and patient care using 5-point Likert scale and open-ended questions. Following roll-out (1 and 6 months), both teams were surveyed with same questions. Results were compared using Wilcoxon–Mann–Whitney test (0–1 months and then 0–6 months). Open-ended question results were qualitatively compared for recurrent unifying themes. Results In both nursing and resident domains, 1 month after implementation, the new communication system was perceived to significantly improve efficiency and patient care across all metrics. After 6 months, this effect decayed in nearly all categories (including efficiency, real-time communication, and knowledge of covering provider). The exception was nurse's knowledge of which resident to contact and resident's timely evaluation of patient, for which we observed sustained improvements. System shortcomings identified included interrupted connection (i.e., dropped calls), dysfunctional and inaccurate alert system, and unclear identification of the covering provider. Conclusion A new text-messaging–based communication system may improve efficiency and patient care in emergent settings, but system shortcomings can substantially erode potential benefits over time. We recommend implementers evaluate new systems for a set of specific functional requirements to increase probability of sustained improvement and decrease risk of poor patient outcomes.
      Citation: Appl Clin Inform 2019; 10: 879-887
      PubDate: 2019-11-20T00:00:00+0100
      DOI: 10.1055/s-0039-1700868
      Issue No: Vol. 10, No. 05 (2019)
  • Use of an EHR-Integrated Point-of-Care Mobile Medical Photography
           Application in a Pediatric Emergency Department
    • Authors: Castillo; Richmond M., Kim, Grace Y., Wyatt, Kirk D., Lohse, Christine M., Hellmich, Thomas R.
      Pages: 888 - 897
      Abstract: Background Mobile applications allow health care providers to capture point-of-care medical photographs and transfer them to the electronic health record (EHR). It is unclear how providers use these photographs or how they affect clinical care. Objectives We aimed to understand the content, purpose, and outcomes of point-of-care medical photography performed in the pediatric emergency department (ED) at large academic medical center. Methods A retrospective chart review was conducted of patients
      Citation: Appl Clin Inform 2019; 10: 888-897
      PubDate: 2019-11-20T00:00:00+0100
      DOI: 10.1055/s-0039-1700870
      Issue No: Vol. 10, No. 05 (2019)
  • Facilitating Organizational Change to Accommodate an Inpatient Portal
    • Authors: Walker; Daniel M., Gaughan, Alice, Fareed, Naleef, Moffatt-Bruce, Susan, McAlearney, Ann Scheck
      Pages: 898 - 908
      Abstract: Background Patient portals are becoming more commonly used in the hospital inpatient setting. While the potential benefits of inpatient portals are acknowledged, there is a need for research that examines the challenges of portal implementation and the development of best practice approaches for successful implementation. Objective We conducted this study to improve our understanding of the impact of the implementation of an inpatient portal on care team members in the context of a large academic medical center. Our study focused on the perspectives of nursing care team members about the inpatient portal. Methods We interviewed care team members (n = 437) in four phases throughout the 2 years following implementation of an inpatient portal to learn about their ongoing perspectives regarding the inpatient portal and its impact on the organization. Results The perspectives of care team members demonstrated a change in acceptance of the inpatient portal over time in terms of buy-in, positive workflow changes, and acknowledged benefits of the portal for both care team members and patients. There were also changes over time in perspectives of the care team in regards to (1) challenges with new technology, (2) impact of the portal on workflow, and (3) buy-in. Six strategies were identified as important for implementation success: (1) convene a stakeholder group, (2) offer continual portal training, (3) encourage shared responsibility, (4) identify champions, (5) provide provisioning feedback, and (6) support patient use. Conclusion Inpatient portals are recognized as an important tool for both patients and care team members, but the implementation of such a technology can create challenges. Given the perspectives care team members had about the impact of the inpatient portal, our findings suggest implementation requires attention to organizational changes that are needed to accommodate the tool and the development of strategies that can address challenges associated with the portal.
      Citation: Appl Clin Inform 2019; 10: 898-908
      PubDate: 2019-11-27T00:00:00+0100
      DOI: 10.1055/s-0039-1700867
      Issue No: Vol. 10, No. 05 (2019)
  • Evaluating the Impact of Interruptive Alerts within a Health System: Use,
           Response Time, and Cumulative Time Burden
    • Authors: Elias; Pierre, Peterson, Eric, Wachter, Bob, Ward, Cary, Poon, Eric, Navar, Ann Marie
      Pages: 909 - 917
      Abstract: Background Health systems often employ interruptive alerts through the electronic health record to improve patient care. However, concerns of “alert fatigue” have been raised, highlighting the importance of understanding the time burden and impact of these alerts on providers. Objectives Our main objective was to determine the total time providers spent on interruptive alerts in both inpatient and outpatient settings. Our secondary objectives were to analyze dwell time for individual alerts and examine both provider and alert-related factors associated with dwell time variance. Methods We retrospectively evaluated use and response to the 75 most common interruptive (“popup”) alerts between June 1st, 2015 and November 1st, 2016 in a large academic health care system. Alert “dwell time” was calculated as the time between the alert appearing on a provider's screen until it was closed. The total number of alerts and dwell times per provider per month was calculated for inpatient and outpatient alerts and compared across alert type. Results The median number of alerts seen by a provider was 12 per month (IQR 4–34). Overall, 67% of inpatient and 39% of outpatient alerts were closed in under 3 seconds. Alerts related to patient safety and those requiring more than a single click to proceed had significantly longer median dwell times of 5.2 and 6.7 seconds, respectively. The median total monthly time spent by providers viewing alerts was 49 seconds on inpatient alerts and 28 seconds on outpatient alerts. Conclusion Most alerts were closed in under 3 seconds and a provider's total time spent on alerts was less than 1 min/mo. Alert fatigue may lie in their interruptive and noncritical nature rather than time burden. Monitoring alert interaction time can function as a valuable metric to assess the impact of alerts on workflow and potentially identify routinely ignored alerts.
      Citation: Appl Clin Inform 2019; 10: 909-917
      PubDate: 2019-11-27T00:00:00+0100
      DOI: 10.1055/s-0039-1700869
      Issue No: Vol. 10, No. 05 (2019)
  • Sustained Improvement in Inflammatory Bowel Disease Quality Measures Using
           an Electronic Health Record Intervention
    • Authors: Bensinger; Andrew, Wilson, Farra, Green, Patrick, Bloomfeld, Richard, Dharod, Ajay
      Pages: 918 - 926
      Abstract: Background Inflammatory bowel disease (IBD) is a chronic condition with wide variation in treatment and resource utilization because of many different disease presentations and treatment options. In an effort to standardize care and improve health outcomes, several organizations have created performance measures to monitor various aspects of IBD care. Objectives We aimed to assess longitudinal documentation adherence with physician quality reporting system's (PQRS) IBD performance measures before, immediately after, and 1 year following the implementation of a comprehensive electronic health record (EHR) IBD clinical documentation support tool intervention. Methods We reviewed 50 patient charts that were randomly selected from consecutive outpatient IBD visits at our tertiary care center from September 1, 2015 to June 30, 2016, prior to implementation of an IBD-specific note template, order set, and patient education handout on September 1, 2016. Two additional cohorts of 50 patient charts were randomly selected from September 1, 2016 to June 30, 2017 and September 1, 2017 to June 30, 2018. These charts were reviewed to assess adherence of pertinent PQRS performance measures for outpatient IBD care. The project was deemed not human subjects research and received exempt approval by the Institutional Review Board (IRB#: IRB00040399). Results The cohort immediately after the intervention showed significant increases in documentation rates of influenza immunization (19–59%, p 
      Citation: Appl Clin Inform 2019; 10: 918-926
      PubDate: 2019-12-04T00:00:00+0100
      DOI: 10.1055/s-0039-3400293
      Issue No: Vol. 10, No. 05 (2019)
  • The Effect of Eliminating Intermediate Severity Drug-Drug Interaction
           Alerts on Overall Medication Alert Burden and Acceptance Rate
    • Authors: Knight; Amy M., Maygers, Joyce, Foltz, Kimberly A., John, Isha S., Yeh, Hsin Chieh, Brotman, Daniel J.
      Pages: 927 - 934
      Abstract: Objective This study aimed to determine the effects of reducing the number of drug-drug interaction (DDI) alerts in an order entry system. Methods Retrospective pre–post analysis at an urban medical center of the rates of medication alerts and alert acceptance during a 5-month period before and 5-month period after the threshold for firing DDI alerts was changed from “intermediate” to “severe.” To ensure that we could determine varying response to each alert type, we took an in-depth look at orders generating single alerts. Results Before the intervention, 241,915 medication orders were placed, of which 25.6% generated one or more medication alerts; 5.3% of the alerts were accepted. During the postintervention period, 245,757 medication orders were placed of which 16.0% generated one or more medication alerts, a 37.5% relative decrease in alert rate (95% confidence interval [CI]: −38.4 to −36.8%), but only a 9.6% absolute decrease (95% CI: −9.4 to −9.9%). 7.4% of orders generating alerts were accepted postintervention, a 39.6% relative increase in acceptance rate (95% CI: 33.2–47.2%), but only a 2.1% absolute increase (95% CI: 1.8–2.4%). When only orders generating a single medication alert were considered, there was a 69.1% relative decrease in the number of orders generating DDI alerts, and an 85.7% relative increase in the acceptance rate (95% CI: 58.6–126.2%), though only a 1.8% absolute increase (95% CI: 1.3–2.3%). Conclusion Eliminating intermediate severity DDI alerts resulted in a statistically significant decrease in alert burden and increase in the rate of medication alert acceptance, but alert acceptance remained low overall.
      Citation: Appl Clin Inform 2019; 10: 927-934
      PubDate: 2019-12-04T00:00:00+0100
      DOI: 10.1055/s-0039-3400447
      Issue No: Vol. 10, No. 05 (2019)
  • Modeling a Clinical Pathway for Contraception
    • Authors: Sooter; Letha J., Hasley, Steve, Lario, Robert, Rubin, Kenneth S., Hasić, Faruk
      Pages: 935 - 943
      Abstract: Background The Centers for Disease Control and Prevention (CDC) produced a 72-page document titled “U.S. Selective Practice Recommendations for Contraceptive Use” in 2016. This document contains the medical eligibility criteria (MEC) for contraceptive initiation or continuation based on a patient's current health status. Notations such as Business Process Model and Notation (BPMN) and Decision Model and Notation (DMN) might be useful to model such recommendations. Objective Our objective was to use BPMN and DMN to model and standardize the processes and decisions involved in initiating birth control according to the CDC's MEC for birth control initiation. This model could then be incorporated into an electronic health records system or other digital platform. Methods Medical terminology, processes, and decisions were modeled in coordination with the CDC to ensure correctness. Challenges in terminology bindings were identified and categorized. Results A model was successfully produced. Integration of clearly defined data elements proved to be the biggest challenge. Conclusion BPMN and DMN have strengths and weaknesses when modeling medical processes; however, they can be used to successfully create models for clinical pathways.
      Citation: Appl Clin Inform 2019; 10: 935-943
      PubDate: 2019-12-11T00:00:00+0100
      DOI: 10.1055/s-0039-3400749
      Issue No: Vol. 10, No. 05 (2019)
  • Longitudinal Evaluation of Clinical Decision Support to Improve Influenza
           Vaccine Uptake in an Integrated Pediatric Health Care Delivery System,
           Houston, Texas
    • Authors: Bratic; Julia S., Cunningham, Rachel M., Belleza-Bascon, Bella, Watson, Scott K., Guffey, Danielle, Boom, Julie A.
      Pages: 944 - 951
      Abstract: Objective Our study retrospectively evaluated the implementation of an influenza vaccine best practice alert (BPA) in an electronic medical record within an integrated pediatric health care delivery system. Methods An influenza BPA was implemented throughout a large pediatric health care delivery system in Houston, TX, to improve vaccine uptake. Outcomes were measured retrospectively over 3 years of BPA implementation and compared with a control year prior to BPA implementation. Primary outcomes were influenza vaccine uptake, distribution of influenza vaccines ordered by week, proportion of BPA displays ignored, and missed vaccination opportunities. Results Influenza vaccine uptake declined from the pre-BPA year (47.2%; 95% confidence interval [CI]: 47.0, 47.4) to the last study year (45.1%; 95% CI: 44.9, 45.2). BPA displays were increasingly ignored by clinical staff throughout the study years from 59.6% in 2014–2015 to 72.5% in 2016–2017. For providers, BPA displays were ignored less frequently each year from 53.4% in 2014–2015 to 51.4% in 2017–2017. Within the primary care outpatient group, the proportion of missed vaccination opportunities in sick visits decreased from 86.8% during the pre-BPA year to 81.0, 79.8, and 82.7% during the subsequent study years 2014–2015, 2015–2016, and 2016–2017, respectively. Conclusion Implementation of a widespread influenza BPA in an integrated pediatric health care delivery system did not produce meaningful increases in influenza vaccine uptake. Differences between clinical staff and providers on BPA use warrant further investigation.
      Citation: Appl Clin Inform 2019; 10: 944-951
      PubDate: 2019-12-11T00:00:00+0100
      DOI: 10.1055/s-0039-3400748
      Issue No: Vol. 10, No. 05 (2019)
  • Unsupervised Machine Learning of Topics Documented by Nurses about
           Hospitalized Patients Prior to a Rapid-Response Event
    • Authors: Korach; Zfania Tom, Cato, Kenrick D., Collins, Sarah A., Kang, Min Jeoung, Knaplund, Christopher, Dykes, Patricia C., Wang, Liqin, Schnock, Kumiko O., Garcia, Jose P., Jia, Haomiao, Chang, Frank, Schwartz, Jessica M., Zhou, Li
      Pages: 952 - 963
      Abstract: Background In the hospital setting, it is crucial to identify patients at risk for deterioration before it fully develops, so providers can respond rapidly to reverse the deterioration. Rapid response (RR) activation criteria include a subjective component (“worried about the patient”) that is often documented in nurses' notes and is hard to capture and quantify, hindering active screening for deteriorating patients. Objectives We used unsupervised machine learning to automatically discover RR event risk/protective factors from unstructured nursing notes. Methods In this retrospective cohort study, we obtained nursing notes of hospitalized, nonintensive care unit patients, documented from 2015 through 2018 from Partners HealthCare databases. We applied topic modeling to those notes to reveal topics (clusters of associated words) documented by nurses. Two nursing experts named each topic with a representative Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) concept. We used the concepts along with vital signs and demographics in a time-dependent covariates extended Cox model to identify risk/protective factors for RR event risk. Results From a total of 776,849 notes of 45,299 patients, we generated 95 stable topics, of which 80 were mapped to 72 distinct SNOMED CT concepts. Compared with a model containing only demographics and vital signs, the latent topics improved the model's predictive ability from a concordance index of 0.657 to 0.720. Thirty topics were found significantly associated with RR event risk at a 0.05 level, and 11 remained significant after Bonferroni correction of the significance level to 6.94E-04, including physical examination (hazard ratio [HR] = 1.07, 95% confidence interval [CI], 1.03–1.12), informing doctor (HR = 1.05, 95% CI, 1.03–1.08), and seizure precautions (HR = 1.08, 95% CI, 1.04–1.12). Conclusion Unsupervised machine learning methods can automatically reveal interpretable and informative signals from free-text and may support early identification of patients at risk for RR events.
      Citation: Appl Clin Inform 2019; 10: 952-963
      PubDate: 2019-12-18T00:00:00+0100
      DOI: 10.1055/s-0039-3401814
      Issue No: Vol. 10, No. 05 (2019)
  • An Evaluation of System End-User Support during Implementation of an
           Electronic Health Record Using the Model for Improvement Framework
    • Authors: Kiepek; Wendy, Sengstack, Patricia P.
      Pages: 964 - 971
      Abstract: Background Electronic health record (EHR) system implementation is complex. Strong support for clinicians and other end-users during the initial phase of implementation requires dedicated resources and commitment to ensure a smooth transition, reduce frustration, and assist in adoption. Objectives Evaluate end-user support processes and personnel employed during the initial phase of EHR implementation at an academic medical center and identify facilitators of success, challenges, and lessons learned. Methods Using the model for improvement framework, this case report describes the activities that follow the concepts of planning, doing, studying, and acting (PDSA) when providing on-site support to system end users during an EHR implementation in a complex health care system. Results Strengths included engaged and supportive leadership, use of internal support personnel, use of zone leaders, daily huddles for effective dissemination of information, and an evaluation survey tool to provide data supporting rapid changes in support personnel allocation. Challenges primarily surrounded the management of over 1,000 external support personnel which included limited EHR system knowledge, scheduling, and transportation logistics. Conclusion Implementation of EHR systems continues. Supporting end users is one aspect of these complex projects that require dedicated resources to manage effectively. Organizations taking a more proactive approach, based on learning from experiences, as well as from other health care organizations, can improve their ability to take on this challenge armed with best practices and lessons learned.
      Citation: Appl Clin Inform 2019; 10: 964-971
      PubDate: 2019-12-18T00:00:00+0100
      DOI: 10.1055/s-0039-3402450
      Issue No: Vol. 10, No. 05 (2019)
  • Provider Preference in Exam Room Layout Design and Computing
    • Authors: Read; Jacob M., Weiler, Dustin T., Satterly, Tyler, Soares, Catarina, Saleem, Jason J.
      Pages: 972 - 980
      Abstract: Background The introduction of the electronic health record (EHR) has had a significant impact on provider–patient interactions, particularly revolving around patient-centeredness. More research is needed to understand the provider perspective of this interaction. Objectives Our objective was to obtain provider feedback on a new exam room design compared with the one already in use with respect to the computing layout, which included a wall-mounted monitor for ease of (re)-positioning. An additional objective was to understand elements of exam room design and computing that were highly valued. Methods Semistructured interviews were conducted with 28 providers from several health care organizations. Interviews were audio recorded and transcribed for analysis. We used an inductive coding approach to abstract recurrent themes from the data. Results Our analysis revealed several themes organized around exam room layout, exam room computing, and provider workflow. We report frequency of occurrence of the coded data for computer accessories, computing usefulness, computer mobility, documentation habits, form factor, layout preference, patient interaction, screen sharing, and work habits. Conclusion Providers in our study preferred exam room design to promote flexibility, mobility, and body orientation directed toward the patient. Providers also expressed the need for exam room design to support varying work habits and preferences, including whether to share the computer screen or not.
      Citation: Appl Clin Inform 2019; 10: 972-980
      PubDate: 2019-12-25T00:00:00+0100
      DOI: 10.1055/s-0039-3401813
      Issue No: Vol. 10, No. 05 (2019)
  • Formative Usability Testing Reduces Severe Blood Product Ordering Errors
    • Authors: Orenstein; Evan W., Boudreaux, Jeanne, Rollins, Margo, Jones, Jennifer, Bryant, Christy, Karavite, Dean, Muthu, Naveen, Hike, Jessica, Williams, Herb, Kilgore, Tania, Carter, Alexis B., Josephson, Cassandra D.
      Pages: 981 - 990
      Abstract: Background Medical errors in blood product orders and administration are common, especially for pediatric patients. A failure modes and effects analysis in our health care system indicated high risk from the electronic blood ordering process. Objectives There are two objectives of this study as follows:(1) To describe differences in the design of the original blood product orders and order sets in the system (original design), new orders and order sets designed by expert committee (DEC), and a third-version developed through user-centered design (UCD).(2) To compare the number and type of ordering errors, task completion rates, time on task, and user preferences between the original design and that developed via UCD. Methods A multidisciplinary expert committee proposed adjustments to existing blood product order sets resulting in the DEC order set. When that order set was tested with front-line users, persistent failure modes were detected, so orders and order sets were redesigned again via formative usability testing. Front-line users in their native clinical workspaces were observed ordering blood in realistic simulated scenarios using a think-aloud protocol. Iterative adjustments were made between participants. In summative testing, participants were randomized to use the original design or UCD for five simulated scenarios. We evaluated differences in ordering errors, time on task, and users' design preference with two-sample t-tests. Results Formative usability testing with 27 providers from seven specialties led to 18 changes made to the DEC to produce the UCD. In summative testing, error-free task completion for the original design was 36%, which increased to 66% in UCD (30%, 95% confidence interval [CI]: 3.9–57%; p = 0.03). Time on task did not vary significantly. Conclusion UCD led to substantially different blood product orders and order sets than DEC. Users made fewer errors when ordering blood products for pediatric patients in simulated scenarios when using the UCD orders and order sets compared with the original design.
      Citation: Appl Clin Inform 2019; 10: 981-990
      PubDate: 2019-12-25T00:00:00+0100
      DOI: 10.1055/s-0039-3402714
      Issue No: Vol. 10, No. 05 (2019)
School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
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