Successful Implementation of Clinical Information Technology: Seven Key Lessons from CPOE.

OBJECTIVES: To identify and describe the most critical strategic and operational contributors to the successful implementation of clinical information technologies, as deployed within a moderate sized system of U.S. community hospitals. BACKGROUND AND SETTING: CHRISTUS Health is a multi-state system comprised of more than 350 services and 60 hospitals with over 9 000 physicians. The Santa Rosa region of CHRISTUS Health, located in greater San Antonio, Texas is comprised of three adult community hospital facilities and one Children's hospital each with bed capacities of 142-180. Computerized Patient Order Entry (CPOE) was first implemented in 2012 within a complex market environment. The Santa Rosa region has 2 417 credentialed physicians and 263 mid-level allied health professionals. METHODS: This report focuses on the seven most valuable strategies deployed by the Health Informatics team in a large four hospital CHRISTUS region to achieve strong CPOE adoption and critical success lessons learned. The findings are placed within the context of the literature describing best practices in health information technology implementation. RESULTS: While the elements described involved discrete de novo process generation to support implementation and operations, collectively they represent the creation of a new customer-centric service culture in our Health Informatics team, which has served as a foundation for ensuring strong clinical information technology adoption beyond CPOE. CONCLUSION: The seven success factors described are not limited in their value to and impact on CPOE adoption, but generalize to - and can advance success in - varied other clinical information technology implementations across diverse hospitals. A number of these factors are supported by reports in the literature of other institutions' successful implementations of CPOE and other clinical information technologies, and while not prescriptive to other settings, may be adapted to yield value elsewhere.

Effect of age on the susceptibility of zebrafish eggs to industrial wastewater.

Toxic effects of 40% (v/v) and 60% (v/v) concentrations of wastewater from the industrial sector of chemical production on eggs of the zebrafish (Danio rerio) were investigated. Significant poisonous effects could be registered in test solutions containing 40% wastewater for eggs up to 0.5 h of age. Solutions containing 60% wastewater affected the mortality of the exposed eggs up to 1 h of age. Earlier stages were more sensitive to industrial wastewater than later stages. The differences in susceptibility must be ascribed to the ontogenetic stage of the eggs at which the experiment was started and to differences in the chorion permeability. The chorion is less permeable after hardening and works as a barrier to detrimental wastewater contents. This circumstance explains the higher viability of zebrafish eggs at the age of > 1 h. When using early stages of the zebrafish for ecological risk estimations, the eggs should, at best, not exceed the age of 0.5 h.

Sensitivity and significance of luminescent bacteria in chronic toxicity testing based on growth and bioluminescence.

This study explored the use of luminescent bacteria (Vibrio fischeri) for chronic aquatic toxicity tests. The evaluated inhibition of growth to Cu2+, Cr6+, Zn2+, Hg2+, Cd2+, Pb2+, cetyl-trimethylammonium bromide, 3,4-dichloroaniline, acetone, dimethylsulfoxide, ethanol, nitrobenzene, methanol, and 3,5-dichlorophenol was compared with results from another investigation, where the inhibition was determined by bioluminescence. Growth inhibition was found to indicate more reliably the presence of substances with chronic toxic properties than the loss of bioluminescence. But growth responded weaker to the majority of the analyzed toxicants than bioluminescence. This must be connected with the test parameters and the experimental conditions. But among growth experiments with freshwater bacteria species the sensitivity of the growth inhibition assay with V. fischeri is competitive when a poor medium is employed.

Development of an optimal bacterial medium based on the growth inhibition assay with Vibrio fischeri.

Chronic toxicity level of chemicals to bacteria can depend on composition and concentration of medium ingredients. This was demonstrated by means of a growth rate inhibition test with the marine bacterium V. fischeri. In a minimal medium (following the validity criterion of achieving a least cell multiplication rate) containing only yeast extract as organic nutrient component, V. fischeri was to Cu2+ 11.9 times, to Hg2+ 3 times and to Zn2+ 2.8 times more sensitive than in the complete defined medium. Obviously yeast extract did not interfere greatly in the complexation mechanisms. The detection limits of the toxicity of Cd2+, 3,5-dichorophenol and nitrobenzene were not influenced by the substrate.

AIDS and prehospital personnel: knowledge and prevention of occupational exposure.

OBJECTIVES: Prehospital personnel, including law enforcement officers, paramedics, and fire-fighters, may be exposed to the human immunodeficiency virus (HIV) while working. This study of prehospital personnel sought to determine: 1) their knowledge of the acquired immune syndrome (AIDS) and HIV transmission; 2) the extent of AIDS training received; 3) self-assessment of risk for HIV infection; and 4) precautions adopted to reduce occupational risk of exposure to HIV. METHODS: A survey was administered to pre-hospital personnel in a large Southern California jurisdiction. The response rate was 41% (n = 1,756) in 10 city and county departments where respondents were employed. Law enforcement officers (44%), firefighters (44%), and paramedics (12%) comprised the sample. RESULTS: Respondents had accurate knowledge about AIDS, but incorrect perceptions about HIV transmission. A minority believed that HIV could be contracted from casual contact. Training relating to AIDS was not frequent. Preventive practices were infrequent in the work setting, with precautions used less than 50% of the time on eight of 10 measures. One-third of these prehospital personnel assessed their risk for HIV infection as medium to high, largely attributable to fear of occupational exposure. CONCLUSIONS: Improved educational programs regarding HIV/AIDS are needed for prehospital personnel to increase the use of preventive occupational practices in the field.

Non-governmental organizations in international health: past successes, future challenges.

Non-governmental organizations, or NGOs, are increasingly instrumental to the implementation of international health programs. Following an overview of current conditions in global health and the problems that could be targeted by NGOs, this article describes the activities and philosophies of several representative approaches in this sector. The attributes of NGOs that increase their potential effectiveness are discussed, including ability to reach areas of severe need, promotion of local involvement, low cost of operations, adaptiveness and innovation, independence, and sustainability. A summary is provided of major future challenges in international health that may be addressed by NGOs, with particular emphasis on tobacco-related disease, communicable diseases and the AIDS epidemic, maternal mortality and women's health, injury prevention and control, and the need to secure durable financial support.

PIP: Nongovernmental organizations (NGOs) have provided humanitarian assistance (relief, disaster assistance, and food distribution) abroad for at least 100 years. Over the last two decades, they have also worked towards alleviating the causes of poverty and improving the quality of life. NGOs have attributes making them uniquely effective in providing international health services. They can reach areas of great need in both rural and urban areas, particularly helping the poor, the dispossessed, and the isolated. NGOs foster community participation. Since they tend to be committed for the long term, they form close bonds with community groups and institutions, resulting in strong support for their services. NGOs tend to operate at low cost due to mission-minded and committed staff working for a stipend or low wages, use of low cost technology, and streamlined services. They have the flexibility to be adaptive and innovative. NGOs usually are apolitical organizations that have a local nonpartisan status, engendering greater acceptance by government and the community. They strive for outcomes that are sustainable. They have been effective in setting up sustainable primary health care delivery systems. NGOs focus on a variety of areas. Some are dedicated to a single organ system (e.g., the eye, Orbis and Helen Keller International). Others focus on the prevention, treatment, or elimination of a single disease (e.g., guinea worm infection, President Carter's Global 2000 project). The primary mission of Project HOPE is health education, particularly training of health professionals in developing countries to become medical and health care faculty. The French NGO Medecins Sans Frontiere (MSF) focuses on human rights issues and determines interventions based on medical needs whether or not a local government accepts assistance or allows MSF teams to enter. Future challenges facing NGOs include the emerging pandemic of tobacco-related diseases, communicable diseases and the AIDS epidemic, maternal mortality and women's health, injury prevention and control, and sustained financing. NGOs do make a difference in global health.

Strengthening public health practice content in public health training.

U.S. schools of public health have recognized the imperative to strengthen the public health practice content of training for future public health practitioners. Five strategies to develop administrative and curriculum programs within schools of public health to address this need are described: (1) institution of centers for public health program evaluation; (2) creation of automated field placement and apprenticeship programs; (3) formalization of linkages with professional management training programs to create a track for future senior managers of community health agencies; (4) establishment of cross-departmental applied public health faculty tracks; and (5) offering applied public health evaluation scholarships for students. These initiatives may provide incentives for the institution of a public health practice focus within schools of public health.

Humanitarian responses to mass violence perpetrated against vulnerable populations.

This multidisciplinary review links three areas of legitimate inquiry for practitioners of medicine and public health. The first is occurrences of mass violence or genocide perpetrated against vulnerable populations, with a focus on the failure of national and international mechanisms to prevent or predict such violence. The second is evolving concepts of national sovereignty and an emerging framework in which the imperative to assist vulnerable populations supersedes a state's right to self determination. The last is how medical, public health, and other systems of surveillance and rapid assessment of mass violence can accelerate public awareness and facilitate structured, consistent political decision making to prevent mass violence and to provide international humanitarian assistance.

Advancing biomedical engineering in developing nations: Project HOPE and the potential impact of nongovernmental organizations.

Nongovernmental organizations (NGOs) have played a major role in the diffusion of biomedical engineering training to developing nations. This paper reviews the roles and unique attributes of NGOs in biomedical engineering training programs. The activities of one leading NGO in this field, Project HOPE, are discussed with examples drawn from around the world. Future challenges to biomedical engineering in the developing world, and the potential of NGOs to provide a response to these needs, are considered.

HIV/AIDS knowledge and high risk sexual practices among southern California Vietnamese.

OBJECTIVES: Vietnamese immigration to the U.S. since the conclusion of the Vietnam war has been substantial and in Orange County, CA, Vietnamese Americans comprise 3% of the population (the largest community in the US). Our objective was to collect data on the HIV/AIDS knowledge, attitudes and self-reported high risk behaviours within this community. METHODS: A survey instrument was administered anonymously in Vietnamese to 532 respondents in their homes. Individuals from three population strata were randomly sampled: men 18 to 35 years old (N = 193); men 36 to 45 years old (N = 137); and women 18 to 35 years old (N = 202). Data were gathered on: (1) degree of acculturation; (2) knowledge and attitudes towards HIV/AIDS; and (3) self-reported sexual and other high risk practices. RESULTS: Survey data indicated that 38% of respondents were very worried about themselves and 83% were worried about a family member getting AIDS. Knowledge about actual modes of HIV transmission was generally accurate, but a substantial minority still believed that HIV can be transmitted through casual contact, and 68% from needles used in hospitals. Women demonstrated less accurate knowledge than men on five key items. Quarantine of the HIV infected was agreed to by 45%. Twenty-nine percent did not believe that the epidemic would affect them personally, and 49% stated that they did not have enough information about AIDS to protect themselves. Regarding sexual practices, 31% reported never having had sex. Of the others, 8% had two or more sexual partners in the prior 12 months. No same sex behaviour was reported. Six percent of men had visited a female prostitute; of these, 24% had visited 2 or more in the prior 12 months; half of encounters in this time period were outside the US. Substantial percentages of sexually active, unmarried respondents indicated that they never use (17-40%) or only sometimes use (10-32%) condoms. Less than 1% had used injection drugs. CONCLUSIONS: Education should be targeted at the Vietnamese community of southern California to improve knowledge that HIV cannot be contracted through casual contact, to convey information about methods for self-protection, and to reduce high risk sexual practices such as unprotected sex, sex with multiple partners and sex with prostitutes.

Fatalities assessed by the Orange County child death review team, 1989 to 1991.

Interagency child death review teams have emerged in response to the increasing awareness of severe violence perpetrated against children in the United States. Child death review involves a systematic, multidisciplinary, and multiagency process to coordinate data and resources from the coroner, law enforcement, the courts, child protective services, and health care providers. The Orange County, CA team reviews all coroner's cases (unattended death or questionable cause of death) for children 12 years old and younger. This paper describes the interagency review in Orange County and provides data on the demographics of cases reviewed by the team (N = 637) compared to unreviewed deaths (N = 1,463) for the period 1989 to 1991. Trends were analyzed to assess differences in: (1) age distribution; (2) gender; (3) ethnicity; (4) cause of death (non-SIDS natural; non-natural including traffic deaths, SIDS, other injuries; homicide; and undetermined); and (5) cause of death by age, gender, and ethnicity. Implications of the data for other jurisdictions with child death review teams are discussed.