A Novel Patient Values Tab for the Electronic Health Record: A User-Centered Design Approach.

BACKGROUND: The COVID-19 pandemic has shined a harsh light on a critical deficiency in our health care system: our inability to access important information about patients' values, goals, and preferences in the electronic health record (EHR). At Memorial Sloan Kettering Cancer Center (MSK), we have integrated and systematized health-related values discussions led by oncology nurses for newly diagnosed cancer patients as part of routine comprehensive cancer care. Such conversations include not only the patient's wishes for care at the end of life but also more holistic personal values, including sources of strength, concerns, hopes, and their definition of an acceptable quality of life. In addition, health care providers use a structured template to document their discussions of patient goals of care. OBJECTIVE: To provide ready access to key information about the patient as a person with individual values, goals, and preferences, we undertook the creation of the Patient Values Tab in our center's EHR to display this information in a single, central location. Here, we describe the interprofessional, interdisciplinary, iterative process and user-centered design methodology that we applied to build this novel functionality as well as our initial implementation experience and plans for evaluation. METHODS: We first convened a working group of experts from multiple departments, including medical oncology, health informatics, information systems, nursing informatics, nursing education, and supportive care, and a user experience designer. We conducted in-depth, semistructured, audiorecorded interviews of over 100 key stakeholders. The working group sought consensus on the tab's main content, homing in on high-priority areas identified by the stakeholders. The core content was mapped to various EHR data sources. We established a set of high-level design principles to guide our process. Our user experience designer then created wireframes of the tab design. The designer conducted usability testing with physicians, nurses, and other health professionals. Data validation testing was conducted. RESULTS: We have already deployed the Patient Values Tab to a pilot sample of users in the MSK Gastrointestinal Medical Oncology Service, including physicians, advanced practice providers, nurses, and administrative staff. We have early evidence of the positive impact of this EHR innovation. Audit logs show increasing use. Many of the initial user comments have been enthusiastically positive, while others have provided constructive suggestions for additional tab refinements with respect to format and content. CONCLUSIONS: It is our challenge and obligation to enrich the EHR with information about the patient as a person. Realization of this capability is a pressing public health need requiring the collaboration of technological experts with a broad range of clinical leaders, users, patients, and families to achieve solutions that are both principled and practical. Our new Patient Values Tab represents a step forward in this important direction.

Expanding Health Information Exchange Improves Identification of Frequent Emergency Department Users.

STUDY OBJECTIVE: Frequent emergency department (ED) users are of interest to policymakers and hospitals. The objective of this study is to examine the effect of health information exchange size on the identification of frequent ED users. METHODS: We retrospectively analyzed data from Healthix, a health information exchange in New York that previously included 10 hospitals and then grew to 31 hospitals. We divided patients into 3 cohorts: high-frequency ED users with 4 or more visits in any 30-day period, medium-frequency ED users with 4 or more visits in any year, and infrequent ED users with fewer than 4 visits in any year. For both the smaller (10-hospital) and larger (31-hospital) health information exchanges, we compared the identification rate of frequent ED users that was based on hospital-specific data with the corresponding rates that were based on health information exchange data. RESULTS: The smaller health information exchange (n=1,696,279 unique ED patients) identified 11.4% more high-frequency users (33,467 versus 30,057) and 9.5% more medium-frequency users (109,497 versus 100,014) than the hospital-specific data. The larger health information exchange (n=3,684,999) identified 19.6% more high-frequency patients (52,727 versus 44,079) and 18.2% more medium-frequency patients (222,574 versus 192,541) than the hospital-specific data. Expanding from the smaller health information exchange to the larger one, we found an absolute increase of 8.2% and 8.7% identified high- and medium-frequency users, respectively. CONCLUSION: Increasing health information exchange size more accurately reflects how patients access EDs and ultimately improves not only the total number of identified frequent ED users but also their identification rate.

Assessing Impressions of Community Health Worker Use of Tablet-Based Medication Documentation Software.

Community health workers, an important and emerging role in the evolution of the care delivery system, are uniquely positioned to play a vital role in information gathering and exchange. NewYork-Presbyterian Hospital carried out a feasibility study to assess community health worker use and impressions of a medication documentation application that runs on a tablet. The nine community health workers successfully collected data on 16 patients in the home setting. On average, 10 medications were collected per patient, and the average time to collect the medication data was 1 hour. Key findings from the focus groups included the need for additional training and the desire to use the device to streamline other documentation activities. In general, the software was judged to be suitable for the proposed task and represents a starting point for further use of tools that leverage the community health worker in a team-based workflow.

Opportunities and Challenges for Augmented Reality in Family Caregiving: Qualitative Video Elicitation Study.

BACKGROUND: Although family caregivers play a critical role in care delivery, research has shown that they face significant physical, emotional, and informational challenges. One promising avenue to address some of caregivers' unmet needs is via the design of digital technologies that support caregivers' complex portfolio of responsibilities. Augmented reality (AR) applications, specifically, offer new affordances to aid caregivers as they perform care tasks in the home. OBJECTIVE: This study explored how AR might assist family caregivers with the delivery of home-based cancer care. The specific objectives were to shed light on challenges caregivers face where AR might help, investigate opportunities for AR to support caregivers, and understand the risks of AR exacerbating caregiver burdens. METHODS: We conducted a qualitative video elicitation study with clinicians and caregivers. We created 3 video elicitations that offer ways in which AR might support caregivers as they perform often high-stakes, unfamiliar, and anxiety-inducing tasks in postsurgical cancer care: wound care, drain care, and rehabilitative exercise. The elicitations show functional AR applications built using Unity Technologies software and Microsoft Hololens2. Using elicitations enabled us to avoid rediscovering known usability issues with current AR technologies, allowing us to focus on high-level, substantive feedback on potential future roles for AR in caregiving. Moreover, it enabled nonintrusive exploration of the inherently sensitive in-home cancer care context. RESULTS: We recruited 22 participants for our study: 15 clinicians (eg, oncologists and nurses) and 7 family caregivers. Our findings shed light on clinicians' and caregivers' perceptions of current information and communication challenges caregivers face as they perform important physical care tasks as part of cancer treatment plans. Most significant was the need to provide better and ongoing support for execution of caregiving tasks in situ, when and where the tasks need to be performed. Such support needs to be tailored to the specific needs of the patient, to the stress-impaired capacities of the caregiver, and to the time-constrained communication availability of clinicians. We uncover opportunities for AR technologies to potentially increase caregiver confidence and reduce anxiety by supporting the capture and review of images and videos and by improving communication with clinicians. However, our findings also suggest ways in which, if not deployed carefully, AR technologies might exacerbate caregivers' already significant burdens. CONCLUSIONS: These findings can inform both the design of future AR devices, software, and applications and the design of caregiver support interventions based on already available technology and processes. Our study suggests that AR technologies and the affordances they provide (eg, tailored support, enhanced monitoring and task accuracy, and improved communications) should be considered as a part of an integrated care journey involving multiple stakeholders, changing information needs, and different communication channels that blend in-person and internet-based synchronous and asynchronous care, illness, and recovery.

Potential unintended consequences of health information exchange.

Accountable models of care delivery demand that health care provider organizations be able to exchange clinical data about the patient. The "Meaningful Use" program is helping to advance health information exchange by requiring physicians and hospitals to exchange clinical data about patients in order to qualify for incentive payments for electronic health records. Early studies demonstrate that the ability to exchange clinical data among provider organizations has the potential to improve clinical care. However, as with any technology, there is a risk of unintended consequences from health information exchange. This manuscript outlines seven aspects of health information exchange that, if not managed properly, may lead to unintended consequences. These categories are: (1) the desire for complete, accurate and timely data for decision making, (2) data management and presentation, (3) assuring routine use of health information exchange, (4) consideration of patient perceptions and concerns, (5) reputational and financial concerns, (6) technical issues and (7) administrative aspects of health information exchange. Education about the capabilities and limitations of health information exchange, along with checklists to support proper implementation and assure that systems are being used as planned, can mitigate risks and help to realize the promise of this powerful technology.

Electronic Consent at US Cancer Centers: A Survey of Practices, Challenges, and Opportunities.

PURPOSE: Digital technologies create opportunities for improving consenting processes in cancer care and research. Yet, little is known about the prevalence of electronic consenting, or e-consent, at US cancer care institutions. METHODS: We surveyed institutions in the National Comprehensive Cancer Network about their capabilities for clinical, research, and administrative e-consents; technologies used; telemedicine consents; multilingual support; evaluations; and opportunities and challenges in moving from paper-based to electronic processes. Responses were summarized across responding institutions. RESULTS: Twenty-five institutions completed the survey (81% response rate). Respondents were from all census regions and included freestanding and matrix cancer centers. Twenty (80%) had e-consent capabilities, with variability in the extent of adoption: One (5%) had implemented e-consent for all clinical, research, and administrative needs while 19 (95%) had a mix of paper and electronic consenting. Among those with e-consent capabilities, the majority (14 of 20, 70%) were using features embedded in their electronic health record. Most had a combination of paper and e-consenting for clinical purposes (18, 72%). About two-thirds relied entirely on paper for research consents (16, 64%) but had at least some electronic processes for administrative consents (15, 60%). Obstacles to e-consenting included challenges with procuring or maintaining hardware, content management, workflow integration, and digital literacy of patients. Successes included positive user experiences, workflow improvements, and better record-keeping. Only two of 20 (10%) respondents with e-consent capabilities had evaluated the impact of automating consent processes. CONCLUSION: E-consent was prevalent in our sample, with 80% of institutions reporting at least some capabilities. Further progress is needed for the benefits of e-consenting to be realized broadly.

Assessment of Oncology Patient Engagement and Interest in Virtual Mind-Body Programming: Moving Toward Personalization of Virtual Care.

PURPOSE: Accelerated by the COVID-19 pandemic, the virtual platform has become a prominent medium to deliver mind-body therapies, but the extent to which patients engage in virtual mind-body programming remains unclear. This study aims to assess oncology patient engagement in a virtual mind-body program. METHODS: We surveyed oncology patients enrolled in a live-streamed (synchronous) virtual mind-body program in May 2021. Patients self-reported engagement by weekly attendance. We applied multivariate regression to identify associations of engagement with sociodemographic and clinical factors. As an exploratory analysis, we used machine learning to partition engagement subgroups to determine preferential interest in prerecorded (asynchronous) mind-body therapy videos. RESULTS: Among 148 patients surveyed (response rate: 21.4%), majority were female (94.5%), White (83.1%), age 65 years or older (64.9%), retired (64.2%), and in survivorship (61.8%). Patient engagement ranged from 1 to 13 classes/week (mean [standard deviation]: 4.23 [2.56]) and was higher for female (ß, .82; 95% CI, 0.01 to 1.62), non-White (ß, .63; 95% CI, 0.13 to 1.13), and retired patients (ß, .50; 95% CI, 0.12 to 0.88). The partition model identified three engagement subgroups: employed (low engagers), retired White (intermediate engagers), and retired non-White (high engagers). Particularly, low engagers had preferential interest in meditation videos (odds ratio, 2.85; 95% CI, 1.24 to 6.54), and both low and high engagers had preferential interest in Tai Chi videos (odds ratio, 2.26; 95% CI, 1.06 to 4.82). CONCLUSION: In this cross-sectional study among oncology patients, engagement in virtual mind-body programming was higher for female, non-White, and retired patients. Our findings suggest the need for both synchronous and asynchronous mind-body programming to meet the diverse needs of oncology patients.

Development and evaluation of an ontology for guiding appropriate antibiotic prescribing.

OBJECTIVES: To develop and apply formal ontology creation methods to the domain of antimicrobial prescribing and to formally evaluate the resulting ontology through intrinsic and extrinsic evaluation studies. METHODS: We extended existing ontology development methods to create the ontology and implemented the ontology using Protégé-OWL. Correctness of the ontology was assessed using a set of ontology design principles and domain expert review via the laddering technique. We created three artifacts to support the extrinsic evaluation (set of prescribing rules, alerts and an ontology-driven alert module, and a patient database) and evaluated the usefulness of the ontology for performing knowledge management tasks to maintain the ontology and for generating alerts to guide antibiotic prescribing. RESULTS: The ontology includes 199 classes, 10 properties, and 1636 description logic restrictions. Twenty-three Semantic Web Rule Language rules were written to generate three prescribing alerts: (1) antibiotic-microorganism mismatch alert; (2) medication-allergy alert; and (3) non-recommended empiric antibiotic therapy alert. The evaluation studies confirmed the correctness of the ontology, usefulness of the ontology for representing and maintaining antimicrobial treatment knowledge rules, and usefulness of the ontology for generating alerts to provide feedback to clinicians during antibiotic prescribing. CONCLUSIONS: This study contributes to the understanding of ontology development and evaluation methods and addresses one knowledge gap related to using ontologies as a clinical decision support system component-a need for formal ontology evaluation methods to measure their quality from the perspective of their intrinsic characteristics and their usefulness for specific tasks.

Notifications of hospital events to outpatient clinicians using health information exchange: a post-implementation survey.

BACKGROUND: The trend towards hospitalist medicine can lead to disjointed patient care. Outpatient clinicians may be unaware of patients' encounters with a disparate healthcare system. Electronic notifications to outpatient clinicians of patients' emergency department (ED) visits and inpatient admissions and discharges using health information exchange can inform outpatient clinicians of patients' hospital-based events. OBJECTIVE: Assess outpatient clinicians' impressions of a new, secure messaging-based, patient event notification system. METHODS: Twenty outpatient clinicians receiving notifications of hospital-based events were recruited and 14 agreed to participate. Using a semi-structured interview, clinicians were asked about their use of notifications and the impact on their practices. RESULTS: Nine of 14 interviewed clinicians (64%) thought that without notifications, they would have heard about fewer than 10% of ED visits before the patient's next visit. Nine clinicians (64%) thought that without notifications, they would have heard about fewer than 25% of inpatient admissions and discharges before the patient's next visit. Six clinicians (43%) reported that they call the inpatient team more often because of notifications. Eight users (57%) thought that notifications improved patient safety by increasing their awareness of the patients' clinical events and their medication changes. Key themes identified were the importance of workflow integration and a desire for more clinical information in notifications. CONCLUSIONS: The notification system is perceived by clinicians to be of value. These findings should instigate further message-oriented use of health information exchange and point to refinements that can lead to even greater benefits.

Analysis of a Remote Monitoring Program for Symptoms Among Adults With Cancer Receiving Antineoplastic Therapy.

IMPORTANCE: Electronic patient-reported outcomes (ePROs) may have the potential to improve cancer care delivery by enhancing patient quality of life, reducing acute care visits, and extending overall survival. However, the optimal cadence of ePRO assessments is unknown. OBJECTIVE: To determine patient response preferences and the clinical value associated with a daily cadence for ePROs for patients receiving antineoplastic treatment. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study of adult patients undergoing antineoplastic treatment assessed a remote monitoring program using ePROs that was developed to manage cancer therapy-related symptoms. ePRO data submitted between October 16, 2018 to February 29, 2020, from a single regional site within the Memorial Sloan Kettering Cancer Center network were included. Data were analyzed from April 2020 to January 2022. EXPOSURE: While undergoing active treatment, patients received a daily ePRO assessment that, based on patient responses, generated yellow (moderate) or red (severe) symptom alerts that were sent to clinicians. MAIN OUTCOMES AND MEASURES: The main outcomes assessed included patient response rate, symptom alert frequency, and an analysis of the clinical value of daily ePROs. RESULTS: A total of 217 patients (median [range] age, 66 [31-92] years; 103 [47.5%] women and 114 [52.5%] men) initiating antineoplastic therapy at high risk for symptoms were monitored for a median (range) of 91 (2-369) days. Most patients had thoracic (59 patients [27.2%]), head and neck (48 patients [22.1%]), or gastrointestinal (43 patients [19.8%]) malignant neoplasms. Of 14 603 unique symptom assessments completed, 7349 (50.3%) generated red or yellow symptom alerts. Symptoms commonly generating alerts included pain (665 assessments [23.0%]) and functional status (465 assessments [16.1%]). Most assessments (8438 assessments [57.8%]) were completed at home during regular clinic hours (ie, 9 am-5 pm), with higher response rates on weekdays (58.4%; 95% CI, 57.5%-59.5%) than on weekend days (51.3%; 95% CI, 49.5%-53.1%). Importantly, 284 of 630 unique red alerts (45.1%) surfaced without a prior yellow alert for the same symptom within the prior 7 days; symptom severity fluctuated over the course of a week, and symptom assessments generating a red alert were followed by an acute care visit within 7 days 8.7% of the time compared with 2.9% for assessments without a red alert. CONCLUSIONS AND RELEVANCE: These findings suggest that daily ePRO assessments were associated with increased insight into symptom management in patients undergoing antineoplastic treatment and symptom alerts were associated with risk of acute care.

ChemoPalRx-A Mobile App That Enhances Chemotherapy Prescription Accuracy: A Cross-Sectional Study.

PURPOSE: ChemoPalRx is a novel provider order entry mobile application for chemotherapy. This study aims to evaluate the accuracy of prescribing chemotherapy using ChemoPalRx versus handwritten orders at a safety-net hospital in Los Angeles. METHODS: In a cross-sectional study from October 2019 to December 2019, we evaluated all outpatient chemotherapy orders for accuracy. Our primary predictor was type of prescription, dichotomized as handwritten or ChemoPalRx. Primary outcome was accuracy, dichotomized as accurate if no error was made on an order and as inaccurate if any error was made. Preplanned subgroup analyses were performed with covariates including provider experience, complexity of order, and day of order submission. We characterized error type and analyzed our data using univariate and multivariate logistic regression models. RESULTS: Among 288 orders (78.5% handwritten; 21.5% ChemoPalRx), prescription accuracy was higher among ChemoPalRx (93.5%) compared with handwritten orders (81.4%; P = .012). In multivariate analysis, prescription accuracy remained superior for ChemoPalRx after adjusting for provider experience, complexity of order, and day of order submission (adjusted odds ratio, 1.82; P = .012). Compared with handwritten orders, ChemoPalRx orders had less missing or incorrect information (1.6% v 13.7%; P = .0016). ChemoPalRx orders were also more accurate on prescriptions that contained two or fewer medications (92.2% v 80.2%; P = .032), submitted on the highest patient-volume clinic day of the week (96.7% v 83.2%; P = .035), and generated by a senior fellow or an attending (97.3% v 76.9%; P = .001). CONCLUSION: ChemoPalRx is associated with improved chemotherapy prescription accuracy over handwritten orders in the safety-net hospital setting and may serve as an alternative prescribing tool for oncology practices.

Needs and Perspectives of Cancer Center Stakeholders for Access to Patient Values in the Electronic Health Record.

PURPOSE: High-quality cancer care must incorporate patients' personal values in decision making throughout illness. Unfortunately, patient values are neither consistently elicited nor easily accessible in the electronic health record (EHR). Memorial Sloan Kettering Cancer Center is deploying a major EHR innovation, called the Patient Values Tab, which provides ready access to patients' values and personhood. To inform the Tab's design, we interviewed a large, diverse group of institutional stakeholders to understand their user needs for this Tab. METHODS: Qualitative data were collected through semistructured, audio-recorded, in-person, individual interviews. An interdisciplinary team of four coders conducted a process of thematic content analysis. Thematic saturation was achieved, and member checking was performed. RESULTS: A total of 110 stakeholders were approached and interviewed. Participants comprised a wide range of disciplines or professions and others involved in hospital and/or clinic administration. Analysis revealed the following themes related to important Tab content: personhood, support system or resources, social history, communication preferences, future planning, end of life, and illness and treatment understanding. Participants also discussed implementation considerations, the Tab's potential to improve communication, and privacy implications. CONCLUSION: This study focused on a major EHR innovation to centralize information about values and personhood of patients with cancer. We elicited views of over 100 institutional stakeholders through in-depth interviews that were rigorously analyzed, yielding themes related to content and format that helped guide the Tab's design. The interviews generated a sense of ownership and enthusiasm for the Tab among future users. The Tab's introduction advances the use of the EHR as a driver of the delivery of patient-centered care.

Applying User-Centered Design in the Electronic Health Record (EHR) to Facilitate Patient-Centered Care in Oncology.

Patient-centered care is an essential component of quality health care. To support patient-centered care initiatives at our institution, we created a feature in our EHR to centrally view information about the patient's values, goals and preferences. We applied user-centered design methods to ensure that the aggregate view was easy to use and would meet user needs. We created a six-week plan to iterate through increasingly detailed design mock-ups. We defined 7 user stories that later served as a basis for user testing scripts. We conducted user testing on our third design iteration; we reached theme saturation with 8 testing sessions. We incorporated findings into the fourth design (week 6) but continued to refine the design in parallel to development (through week 20+). The advance directives section required the most attention. We will use a pilot and additional user testing to validate the design and to inform future versions.

Challenges to EHR implementation in electronic- versus paper-based office practices.

BACKGROUND: Challenges in implementing electronic health records (EHRs) have received some attention, but less is known about the process of transitioning from legacy EHRs to newer systems. OBJECTIVE: To determine how ambulatory leaders differentiate implementation approaches between practices that are currently paper-based and those with a legacy EHR system (EHR-based). DESIGN: Qualitative study. PARTICIPANTS: Eleven practice managers and 12 medical directors all part of an academic ambulatory care network of a large teaching hospital in New York City in January to May of 2006. APPROACH: Qualitative approach comparing and contrasting perceived benefits and challenges in implementing an ambulatory EHR between practice leaders from paper- and EHR-based practices. Content analysis was performed using grounded theory and ATLAS.ti 5.0. RESULTS: We found that paper-based leaders prioritized the following: sufficient workstations and printers, a physician information technology (IT) champion at the practice, workflow education to ensure a successful transition to a paperless medical practice, and a high existing comfort level of practitioners and support staff with IT. In contrast, EHR-based leaders prioritized: improved technical training and ongoing technical support, sufficient protection of patient privacy, and open recognition of physician resistance, especially for those who were loyal to a legacy EHR. Unlike paper-based practices, EHR-based leadership believed that comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome. CONCLUSIONS: Leadership at paper- and EHR-based practices in 1 academic network has different priorities for implementing a new EHR. Ambulatory practices upgrading their legacy EHR have unique challenges.

Impact of an automated test results management system on patients' satisfaction about test result communication.

BACKGROUND: Few reliable and efficient systems support the communication of test results to outpatients, and this may lead to patient dissatisfaction with test result communication. The objective of this study was to assess the impact of physicians' use of a test results management tool embedded in an electronic health record on patient satisfaction with test result communication. METHODS: A prospective, cluster-randomized, controlled trial of 570 patient encounters in 26 outpatient primary care practices was performed from December 1, 2002, to April 31, 2005. Physicians in the intervention practices were trained and given access to a physician test results management tool with imbedded patient notification functions to evaluate whether patient satisfaction with communication of test results ordered by the primary care provider was improved. Patient satisfaction surveys were conducted by telephone after the patient underwent the test and were administered before and after the intervention in both arms. RESULTS: The survey response rate after successful patient contact was 74.2% (570/768). After adjusting for patient age, sex, race, socioeconomic status, and insurance type, the intervention significantly increased patient satisfaction with test results communication (odds ratio, 2.35; 95% confidence interval, 1.05-5.25; P = .03). In addition, patients in the postintervention group were more satisfied with information given them for medical treatments and conditions regarding their results (odds ratio, 3.45; 95% confidence interval, 1.30-9.17; P = .02). CONCLUSION: An automated test results management system can improve patient satisfaction with communication of test results ordered by their primary care provider and can improve patient satisfaction with the communication of information regarding their condition and treatment plans.

A qualitative analysis of an electronic health record (EHR) implementation in an academic ambulatory setting.

OBJECTIVES: To determine pre-implementation perspectives of institutional, practice and vendor leadership regarding best practice for implementation of two ambulatory electronic health records (EHRs) at an academic institution. DESIGN: Semi-structured interviews with ambulatory care network and information systems leadership, medical directors, practice managers and vendors before EHR implementation. Results were analysed using grounded theory with ATLAS.ti version 5.0. MEASUREMENTS: Qualitative data on perceived benefits of EHRs as well as facilitators and barriers to successful implementation. RESULTS: Interviewees perceived data accessibility, quality and safety measurement, improvement and reporting as benefits of EHR use. Six themes emerged for EHR implementation best practice: effective communication; successful system migration; sufficient hardware, technical equipment, support and training; safeguards for patient privacy; improved efficiency; and a sustainable business plan. CONCLUSIONS: Achieving the benefits of EHRs identified by our interviewees depends on successful implementation and use. Further identification of best implementation practices for EHRs is required, given the financial and clinical consequences of poor implementation.

An Applied Framework in Support of Shared Decision Making about BRCA Genetic Testing.

The United States Preventive Services Taskforce recommends that primary care providers screen patients for an increased risk of carrying a BRCA1 or BRCA2 mutation and refer those who meet family history criteria to genetic counseling. Such screening requires detailed and accurate family history data, which often goes uncollected during a primary care visit due to time constraints, competing priorities, and lack of awareness on behalf of both patients and providers. In order to address these barriers and promote appropriate genetic counseling referral, we developed a user-centered framework that collects and communicates relevant data in order to prepare patients and their primary care providers for an informed discussion on genetic counseling referral. This paper describes this framework and the underlining data schema that makes it possible.

Discovering how to think about a hospital patient information system by struggling to evaluate it: a committee's journal.

Parallel to the monumental problem of replacing paper-and-pen-based patient information management systems with electronic ones is the problem of evaluating the extent to which the change represents an improvement. All clinicians must grapple with this daunting challenge; those with little or no informatics expertise may be particularly surprised by the attendant difficulties. To do so successfully, they must be able to explicitly conceptualize the daily clinical work-a prerequisite for appreciating and reasonably evaluating it. Further, few of these evaluators may have reflected on the dynamic interaction between their work and their tools-how changing a tool necessarily changes the work. This article illuminates these problems by telling the story of how one patient care information systems committee first learned to think about the purpose of a patient information management system, and second, how to evaluate the impact of its implementation.

Medication-related clinical decision support in computerized provider order entry systems: a review.

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.