Development of a Web-based resident profiling tool to support training in practice-based learning and improvement.

Multiple factors are driving residency programs to explicitly address practice-based learning and improvement (PBLI), yet few information systems exist to facilitate such training. We developed, implemented, and evaluated a Web-based tool that provides Internal Medicine residents at the University of Virginia Health System with population-based reports about their ambulatory clinical experiences. Residents use Systems and Practice Analysis for Resident Competencies (SPARC) to identify potential areas for practice improvement. Thirty-three (65%) of 51 residents completed a survey assessing SPARC's usefulness, with 94% agreeing that it was a useful educational tool. Twenty-six residents (51%) completed a before-after study indicating increased agreement (5-point Likert scale, with 5=strongly agree) with statements regarding confidence in ability to access population-based data about chronic disease management (mean [SD] 2.5 [1.2] vs. 4.5 [0.5], p < .001, sign test) and information comparing their practice style to that of their peers (2.2 [1.2] vs. 4.6 [0.5], p < .001).

The development of health care data warehouses to support data mining.

Clinical data warehouses offer tremendous benefits as a foundation for data mining. By serving as a source for comprehensive clinical and demographic information on large patient populations, they streamline knowledge discovery efforts by providing standard and efficient mechanisms to replace time-consuming and expensive original data collection, organization, and processing. Building effective data warehouses requires knowledge of and attention to key issues in database design, data acquisition and processing, and data access and security. In this article, the authors provide an operational and technical definition of data warehouses, present examples of data mining projects enabled by existing data warehouses, and describe key issues and challenges related to warehouse development and implementation.

Reduced Clostridium difficile Tests and Laboratory-Identified Events With a Computerized Clinical Decision Support Tool and Financial Incentive.

We hypothesized that a computerized clinical decision support tool for Clostridium difficile testing would reduce unnecessary inpatient tests, resulting in fewer laboratory-identified events. Census-adjusted interrupted time-series analyses demonstrated significant reductions of 41% fewer tests and 31% fewer hospital-onset C. difficile infection laboratory-identified events following this intervention.Infect Control Hosp Epidemiol 2018;39:737-740.

Electronic health records: high-quality electronic data for higher-quality clinical research.

In the decades prior to the introduction of electronic health records (EHRs), the best source of electronic information to support clinical research was claims data. The use of claims data in research has been criticised for capturing only demographics, diagnoses and procedures recorded for billing purposes that may not fully reflect the patient's condition. Many important details of the patient's clinical status are not recorded. EHRs can overcome many limitations of claims data in research, by capturing a more complete picture of the observations and actions of a clinician recorded when patients are seen. EHRs can provide important details about vital signs, diagnostic test results, social and family history, prescriptions and physical examination findings. As a result, EHRs present a new opportunity to use data collected through the routine operation of a clinical practice to generate and test hypotheses about the relationships among patients, diseases, practice styles, therapeutic modalities and clinical outcomes. This article describes the clinical research information infrastructure at four institutions: the University of Pennsylvania, Regenstrief Institute/Indiana University, Partners Healthcare System and the University of Virginia. We present models for applying EHR data successfully within the clinical research enterprise.

Present-at-admission diagnoses improve mortality risk adjustment and allow more accurate assessment of the relationship between volume of lung cancer operations and mortality risk.

BACKGROUND: Mortality risk adjustment is a key component of studies that examine the statistical relationship between hospital lung cancer operation volume and in-hospital mortality. Previous studies of this relationship have used different methods of adjusting for factors that influence mortality risk, but none have adjusted for differences in comorbid disease using only diagnoses identified as present-at-admission. METHODS: This study uses adjustments for conditions identified as present-at-admission to examine the statistical relationship between the volume of lung cancer operations and mortality among 14,456 California hospital patients, and compares these results to other methods of risk adjustment similar to those used in previous studies. RESULTS: Mortality risk adjustment using present-at-admission diagnoses yielded better discrimination and explained more of the variability in observed deaths. Large increases in hospital procedure volume were associated with much smaller decreases in mortality risk than those estimated using comparable risk-adjustment models. CONCLUSIONS: Present-at-admission diagnoses can be used to improve mortality risk adjustment and may allow a more accurate assessment of the relationship between procedure volume and mortality risk.

Effect of pooled comparative information on judgments of quality.

Quality assessment is the focus of many health care initiatives. Yet it is not well understood how the type of information used in decision support tools to enable judgments of quality based on data impacts the accuracy, consistency and reliability of judgments made by physicians. Comparative pooled information could allow physicians to judge the quality of their practice by making comparisons to other practices or other specific populations of patients. In this study, resident physicians were provided with varying types of information derived from pooled patient data sets: quality component measures at the individual and group level, a qualitative interpretation of the quality measures using percentile rank, and an aggregate composite quality score. 32 participants viewed thirty quality profiles consisting of information applicable to the practice of thirty de-identified resident physicians. Those provided with quality component measures and a qualitative interpretation of the quality measures (rankings) judged quality of care more similarly to experts and were more internally consistent compared to participants who were provided with quality component measures alone. Reliability between participants was significantly less for those who were provided with a composite quality score compared to those who were not.

A cross-site qualitative study of physician order entry.

OBJECTIVE: To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals. DESIGN: A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data. MEASUREMENTS: Patterns and themes concerning perceptions of POE were identified. RESULTS: Four high-level themes were identified: (1) organizational issues such as collaboration, pride, culture, power, politics, and control; (2) clinical and professional issues involving adaptation to local practices, preferences, and policies; (3) technical/implementation issues, including usability, time, training and support; and (4) issues related to the organization of information and knowledge, such as system rigidity and integration. Relevant differences between teaching and nonteaching hospitals include extent of collaboration, staff longevity, and organizational missions. CONCLUSION: An organizational culture characterized by collaboration and trust and an ongoing process that includes active clinician engagement in adaptation of the technology were important elements in successful implementation of physician order entry at the institutions that we studied.

The effect of physician feedback and an action checklist on diabetes care measures.

The objective was to evaluate whether physician feedback accompanied by an action checklist improved diabetes care process measures. Eighty-three physicians in an academic general medicine clinic were provided a single feedback report on the most recent date and result of diabetes care measures (glycosylated hemoglobin [A1c], urine microalbumin, serum creatinine, lipid levels, retinal examination) as well as recent diabetes medication refills with calculated dosing and adherence on 789 patients. An educational session regarding the feedback and adherence information was provided. The physicians were asked to complete a checklist accompanying the feedback on each of their patients, indicating requested actions with respect to follow-up, testing, and counseling. The physicians completed 82% of patient checklists, requesting actions consistent with patient needs on the basis of the feedback. Of the physicians, 93% felt the patient information and intervention format to be useful. The odds of urine microalbumin testing, serum creatinine, lipid profile, A1c, and retinal examination increased in the 6 months after the feedback. The increase was sustained at 1 year only for microalbumin and retinal exams. There was no significant change in refill adherence for the group overall after the feedback, although adherence did improve among patients of physicians attending the educational session. No significant change was noted in lipid or A1c levels during the study period. In conclusion, a simple physician feedback tool with action checklist can be both helpful and popular for improving rates of diabetes care guideline adherence. More complex interventions are likely required to improve diabetes outcomes.

Comorbid disease and the effect of race and ethnicity on in-hospital mortality from aspiration pneumonia.

BACKGROUND: Racial and ethnic disparities in mortality have been demonstrated in several diseases. African Americans are hospitalized at a significantly higher rate than whites for aspiration pneumonia; however, no studies have investigated racial and ethnic disparities in mortality in this population. OBJECTIVE: To assess the independent effect of race and ethnicity on in-hospital mortality among aspiration pneumonia discharges while comprehensively controlling for comorbid diseases, and to assess whether the prevalence and effects of comorbid illness differed across racial and ethnic categories. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 41,581 patients admitted to California hospitals for aspiration pneumonia from 1996 through 1998, using principal and secondary diagnoses present on admission. MEASUREMENT: The primary outcome measure was in-hospital mortality. RESULTS: The adjusted odds of in-hospital death for African-American compared with white discharges [odds ratio (OR)=1.01; 95% confidence interval (CI), 0.91-1.11] was not significantly different. The odds of death for Asian compared with white discharges was significantly lower (OR=0.83; 95% CI, 0.75-0.91). Hispanics had a significantly lower odds of death (OR=0.90; 95% CI, 0.82-0.988) compared to non-Hispanics. Comorbid diseases were more prevalent among African Americans and Asians than whites, and among Hispanics compared to non-Hispanics. Differences in effects of comorbid disease on mortality risk by race and ethnicity were not statistically significant. CONCLUSION: Asians have a lower risk of death, and the risk of death for African Americans is not significantly different from whites in this analysis of aspiration pneumonia discharges. Hispanics have a lower risk of death than non-Hispanics. While there are differences in prevalence of comorbid disease by racial and ethnic category, the effects of comorbid disease on mortality risk do not differ meaningfully by race or ethnicity.

Providing palliative care in the ambulatory care setting.

Palliative care that provides specialized attention to pain and symptom management is important for patients with cancer. Palliative care aims to reduce pain and other symptoms through an interdisciplinary approach involving physicians, nurses, social workers, and other members of the healthcare team. Families are included in care planning. Patients and families benefit from the availability of palliative care services early in the disease process, particularly when symptoms impact quality of life. One way to implement early palliative interventions is the establishment of an ambulatory care clinic dedicated to palliative care. This article describes the experience of an outpatient palliative care clinic at a large teaching hospital by using case studies to highlight the benefits of ambulatory palliative care and concluding with recommendations for research.

Clinical decision support: progress and opportunities.

In 2005, the American Medical Informatics Association undertook a set of activities relating to clinical decision support (CDS), with support from the office of the national coordinator and the Agency for Healthcare Research and Quality. They culminated in the release of the roadmap for national action on CDS in 2006. This article assesses progress toward the short-term goals within the roadmap, and recommends activities to continue to improve CDS adoption throughout the United States. The report finds that considerable progress has been made in the past four years, although significant work remains. Healthcare quality organizations are increasingly recognizing the role of health information technology in improving care, multi-site CDS demonstration projects are under way, and there are growing incentives for adoption. Specific recommendations include: (1) designating a national entity to coordinate CDS work and collaboration; (2) developing approaches to monitor and track CDS adoption and use; (3) defining and funding a CDS research agenda; and (4) updating the CDS 'critical path'.

SUPPORTING PHYSICIANS' PRACTICE-BASED LEARNING AND IMPROVEMENT (PBLI) AND QUALITY IMPROVEMENT THROUGH EXPLORATION OF POPULATION-BASED MEDICAL DATA.

Participating in self-assessment activities may stimulate improvement in practice behaviors. However, it is unclear how best to support the development of self-assessment skills, particularly in the health care domain. Exploration of population-based data is one method to enable health care providers to identify deficiencies in overall practice behavior that can motivate quality improvement initiatives. At the University of Virginia, we are developing a decision support tool to integrate and present population-based patient data to health care providers related to both clinical outcomes and non-clinical measures (e.g., demographic information). By enabling users to separate their direct impact on clinical outcomes from other factors out of their control, we may enhance the self-assessment process.

Formulary access using a PDA-based drug reference tool: does it affect prescribing behavior?

We assessed the association between formulary access via a handheld drug reference tool and utilization of generic (Tier 1) and non-generic, non-formulary (Tier 3) medications. In a retrospective before-after study of physician prescribing behavior for patients in a large, national health plan, physicians with formulary access using Epocrates(TM) showed smaller (0.5%) increases in Tier 3 prescribing over time compared to physicians without such access.

Changing conversations: teaching safety and quality in residency training.

Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Updated review of blood culture contamination.

Blood culture contamination represents an ongoing source of frustration for clinicians and microbiologists alike. Ambiguous culture results often lead to diagnostic uncertainty in clinical management and are associated with increased health care costs due to unnecessary treatment and testing. A variety of strategies have been investigated and employed to decrease contamination rates. In addition, numerous approaches to increase our ability to distinguish between clinically significant bacteremia and contamination have been explored. In recent years, there has been an increase in the application of computer-based tools to support infection control activities as well as provide clinical decision support related to the management of infectious diseases. Finally, new approaches for estimating bacteremia risk which have the potential to decrease unnecessary blood culture utilization have been developed and evaluated. In this review, we provide an overview of blood culture contamination and describe the potential utility of a variety of approaches to improve both detection and prevention. While it is clear that progress is being made, fundamental challenges remain.

Impact of a Web-based diagnosis reminder system on errors of diagnosis.

A large number of medical errors can be attributed to errors in diagnosis. A diagnosis reminder system such as Isabel may lessen the risk of diagnostic error by providing a checklist of possible diagnoses. For this project, resident physicians used Isabel to work through a set of six simulated patient cases. The system had a positive effect on the mean diagnostic quality score and the number of clinically important diagnoses included in the differential.

Improving quality measurement using multiple data sources.

We calculated a sample of AHRQ Quality and Patient Safety Indicators for UVa hospitalized patients over a 3 year period using diagnoses and procedure codes from two different billing systems. Significant differences in results were observed suggesting that quality indicators calculated from hospital billing sources alone may be understated.

Introducing an academic data warehouse into the undergraduate medical curriculum.

There is increasing interest in integrating population health and informatics topics into the undergraduate medical curriculum, yet little consensus exists on the most effective approach to accomplish this. We introduced the use of an academic data warehouse of encrypted patient information into an existing 2nd year medical school course. Exercises were developed requiring students to retrieve and interpret information regarding local disease prevalence, practice patterns, and patient characteristics. These exercises were integrated into existing weekly problem sets in a multiple-choice format. Faculty and student perceptions were assessed with surveys, and augmented with interviews of student volunteers, and database usage statistics. Our results indicate widespread agreement among both students and faculty that population-based medicine warrants inclusion in undergraduate medical education. The majority of the students felt the exercises complemented the clinical cases around which they were structured. There was less agreement, however, that the exercises were valuable, with several students suggesting a more open-ended, discussion-oriented approach. It was clear that faculty perceptions had a significant impact on student reactions.

Mapping from a clinical data warehouse to the HL7 Reference Information Model.

Large-scale data integration efforts to support clinical and biologic research are greatly facilitated by the adoption of standards for the representation and exchange of data. As part of a larger project to design the necessary architecture for multi-institutional sharing of disparate biomedical data, we explored the potential of the HL7 Reference Information Model (RIM) for representing the data stored in a local academic clinical data warehouse. A necessary first step in information exchange with such a warehouse is the development and utilization of tools for transforming between local data schemas and standards-based conceptual data models. We describe our initial efforts at mapping clinical concepts from a relational data warehouse to the HL7 RIM.