Extending closed-loop control to the management of chronic disease.

A closed-loop control process assures that a system performs within control limits by direct feedback of the system's output to change the system's inputs. We developed methods for the closed-loop control of system-based practice, using ventilator management as a model or test bed. The control system has three components: 1) an explicit end-to-end plan; 2) a record of what is done as it is done; and 3) an instant display of the status of each patient against the plan for that patient. The status display provides process control by showing the clinical team where corrections are needed while the team still has the time needed to act prospectively. We are extending these methods to the management of chronic disease. Their extension requires engagement of the patient as a member of the team, a coordinated plan across the care continuum, informatics algorithms to stratify individual patients according to co-morbidities and their current level of control, and a means of detecting the presence or absence of a reaction to each action taken by the team.

Using SNOMED CT to represent two interface terminologies.

OBJECTIVE: Interface terminologies are designed to support interactions between humans and structured medical information. In particular, many interface terminologies have been developed for structured computer based documentation systems. Experts and policy-makers have recommended that interface terminologies be mapped to reference terminologies. The goal of the current study was to evaluate how well the reference terminology SNOMED CT could map to and represent two interface terminologies, MEDCIN and the Categorical Health Information Structured Lexicon (CHISL). DESIGN: Automated mappings between SNOMED CT and 500 terms from each of the two interface terminologies were evaluated by human reviewers, who also searched SNOMED CT to identify better mappings when this was judged to be necessary. Reviewers judged whether they believed the interface terms to be clinically appropriate, whether the terms were covered by SNOMED CT concepts and whether the terms' implied semantic structure could be represented by SNOMED CT. MEASUREMENTS: Outcomes included concept coverage by SNOMED CT for study terms and their implied semantics. Agreement statistics and compositionality measures were calculated. RESULTS: The SNOMED CT terminology contained concepts to represent 92.4% of MEDCIN and 95.9% of CHISL terms. Semantic structures implied by study terms were less well covered, with some complex compositional expressions requiring semantics not present in SNOMED CT. Among sampled terms, those from MEDCIN were more complex than those from CHISL, containing an average 3.8 versus 1.8 atomic concepts respectively, p<0.001. CONCLUSION: Our findings support using SNOMED CT to provide standardized representations of information created using these two terminologies, but suggest that enriching SNOMED CT semantics would improve representation of the external terms.

Improving delivery of EPSDT well-child care at acute visits in an academic pediatric practice.

BACKGROUND AND OBJECTIVE: Many patients with Medicaid do not receive timely, comprehensive well-child care through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Missed opportunities for EPSDT well-child check-ups (WCCs) at acute visits contribute to this problem. The authors sought to reduce missed opportunities for WCCs at acute visits for patients overdue for those services. METHODS: A quality improvement team developed key drivers and used a people-process-technology framework to devise 3 interventions: (1) an electronic indicator based on novel definitions of EPSDT status (up-to-date, due, overdue, no EPSDT), (2) a standardized scheduling process for acute visits based on EPSDT status, and (3) a dedicated nurse practitioner to provide WCCs at acute visits. Data were collected for 1 year after full implementation. RESULTS: At baseline, 10.3 acute visits per month were converted to WCCs. After intervention, 86.7 acute visits per month were converted. Of 13801 acute visits during the project, 31.2% were not up-to-date. Of those overdue for WCCs, 51.4% (n = 552) were converted to a WCC in addition to the acute visit. Including all patients who were not up-to-date, a total of 1047 acute visits (7.6% of all acute visits) were converted to comprehensive WCCs. Deferring needed WCCs at acute visits resulted in few patients who scheduled or completed future WCC visits. CONCLUSIONS: Implementation of interventions focused on people-process-technology significantly increased WCCs at acute visits within a feasible and practical model that may be replicated at other academic general pediatrics practices.

A computerized pneumococcal vaccination reminder system in the adult emergency department.

BACKGROUND: Pneumococcal vaccination is an effective strategy to prevent invasive pneumococcal disease in the elderly. Emergency department (ED) visits present an underutilized opportunity to increase vaccination rates; however, designing a sustainable vaccination program in an ED is challenging. We examined whether an information technology supported approach would provide a feasible and sustainable method to increase vaccination rates in an adult ED. METHODS: During a 1-year period we prospectively evaluated a team-oriented, workflow-embedded reminder system that integrated four different information systems. The computerized triage application screened all patients 65 years and older for pneumococcal vaccine eligibility with information from the electronic patient record. For eligible patients the computerized provider order entry system reminded clinicians to place a vaccination order, which was passed to the order tracking application. Documentation of vaccine administration was then added to the longitudinal electronic patient record. The primary outcome was the vaccine administration rate in the ED. Multivariate logistic regression analysis was used to estimate the odds ratios and their 95% confidence intervals, representing the overall relative risks of ED workload related variables associated with vaccination rate. RESULTS: Among 3371 patients 65 years old and older screened at triage 1309 (38.8%) were up-to-date with pneumococcal vaccination and 2062 (61.2%) were eligible for vaccination. Of the eligible patients, 621 (30.1%) consented to receive the vaccination during their ED visit. Physicians received prompts for 428 (68.9%) patients. When prompted, physicians declined to order the vaccine in 192 (30.9%) patients, while 222 (10.8%) of eligible patients actually received the vaccine. The computerized reminder system increased vaccination rate from a baseline of 38.8% to 45.4%. Vaccination during the ED visit was associated younger age (OR: 0.972, CI: 0.953-0.991), Caucasian race (OR: 0.329, CI: 0.241-0.448), and longer ED boarding times (OR: 1.039, CI: 1.013-1.065). CONCLUSION: The integrated informatics solution seems to be a feasible and sustainable model to increase vaccination rates in a challenging ED environment.

Behind-the-scenes of patient-centered care: content analysis of electronic messaging among primary care clinic providers and staff.

BACKGROUND: Transitions to patient-centered health care, the increasing complexity of care, and growth in self-management have all increased the frequency and intensity of clinical services provided outside office settings and between visits. Understanding how electronic messaging, which is often used to coordinate care, affects care is crucial. A taxonomy for codifying clinical text messages into standardized categories could facilitate content analysis of work performed or enhanced via electronic messaging. OBJECTIVE: To codify electronic messages exchanged among the primary care providers and the staff managing diabetes patients at an academic medical center. RESEARCH DESIGN: Retrospective analysis of 27,061 electronic messages exchanged among 578 providers and staff caring for a cohort of 639 adult primary care patients with diabetes between April 1, 2003 and October 31, 2003. SUBJECTS: Providers and staff using locally developed electronic messaging in an academic medical center's adult primary care clinic. MEASURES: Raw data included clinical text message content, message ID, thread ID, and user ID. Derived measures included user job classification, 35 flags codifying message content, and a taxonomy grouping the flags. RESULTS: Messages contained diverse content: communications with patients, families, and other providers (47.2%), diagnoses (25.4%), documentation (33%), logistics and support functions (29.6%), medications (32.9%), and treatments (28.9%). All messages could be classified; 59.5% of messages addressed 2 or more content areas. CONCLUSIONS: Systematic content analysis of provider and staff electronic messages yields specific insight regarding clinical and administrative work carried out via electronic messaging.

Adequacy of representation of the National Drug File Reference Terminology Physiologic Effects reference hierarchy for commonly prescribed medications.

The National Drug File Reference Terminology contains a novel reference hierarchy to describe physiologic effects (PE) of drugs. The PE reference hierarchy contains 1697 concepts arranged into two broad categories; organ specific and generalized systemic effects. This investigation evaluated the appropriateness of the PE concepts for classifying a random selection of commonly prescribed medications. Ten physician reviewers classified the physiologic effects of ten drugs and rated the accuracy of the selected term. Inter reviewer agreement, overall confidence, and concept frequencies were assessed and were correlated with the complexity of the drug's known physiologic effects. In general, agreement between reviewers was fair to moderate (kappa 0.08-0.49). The physiologic effects modeled became more disperse with drugs having and inducing multiple physiologic processes. Complete modeling of all physiologic effects was limited by reviewers focusing on different physiologic processes. The reviewers were generally comfortable with the accuracy of the concepts selected. Overall, the PE reference hierarchy was useful for physician reviewers classifying the physiologic effects of drugs. Ongoing evolution of the PE reference hierarchy as it evolves should take into account the experiences of our reviewers.