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BACKGROUND: The Centers for Medicare & Medicaid Services' Stage 2 final rule requires that eligible hospitals provide a visit summary electronically at transitions of care in order to qualify for "meaningful use" incentive payments. However, Massachusetts state law and Federal law prohibit the transmission of documents containing "sensitive" data unless there is a new patient consent for each transmission. OBJECTIVES: To describe the implementation and evaluation of a rule-based decision support system used to screen transition of care documents for sensitive data. METHODS: We implemented a rule-based document screening system to identify transition of care documents that might contain sensitive data. The transmission of detected documents is withheld until a new patient consent is obtained. The documents that were flagged as containing sensitive data were reviewed in two different time periods to verify that the decision support system was not missing documents or withholding more documents than necessary. RESULTS: The rule-based screening system has been in regular production use for the past 18 months. During the first evaluation period, 3% of 5,841 documents were identified as containing sensitive data (true-positive rate of 44%). After additional enhancements to the rules, the system was evaluated a second time and 4.5% of 6,935 documents were identified as containing sensitive data (true-positive rate of 98.4%). CONCLUSION: The analysis of the system demonstrates that production rules can be used to automatically screen the content of transition of care documents for sensitive data. The utilization of the rule-based decision support system enabled our hospitals to achieve meaningful use and, at the same time, remain compliant with state and federal laws.
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Sistemas de Apoyo a Decisiones Clínicas , Documentación/métodos , Intercambio de Información en SaludRESUMEN
INTRODUCTION: For children who present to emergency departments (EDs) due to blunt head trauma, ED clinicians must decide who requires computed tomography (CT) scanning to evaluate for traumatic brain injury (TBI). The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) who do not typically require CT scans. In this case report, we describe the strategy used to implement the PECARN TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) as the intervention in a multicenter clinical trial. METHODS: Thirteen EDs participated in this trial. The 10 sites receiving the CDS intervention used the Epic(®) EHR. All sites implementing EHR-based CDS built the rules by using the vendor's CDS engine. Based on a sociotechnical analysis, we designed the CDS so that recommendations could be displayed immediately after any provider entered prediction rule data. One central site developed and tested the intervention package to be exported to other sites. The intervention package included a clinical trial alert, an electronic data collection form, the CDS rules and the format for recommendations. RESULTS: The original PECARN head trauma prediction rules were derived from physician documentation while this pragmatic trial led each site to customize their workflows and allow multiple different providers to complete the head trauma assessments. These differences in workflows led to varying completion rates across sites as well as differences in the types of providers completing the electronic data form. Site variation in internal change management processes made it challenging to maintain the same rigor across all sites. This led to downstream effects when data reports were developed. CONCLUSIONS: The process of a centralized build and export of a CDS system in one commercial EHR system successfully supported a multicenter clinical trial.
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Traumatismos Craneocerebrales , Sistemas de Apoyo a Decisiones Clínicas , Niño , Traumatismos Craneocerebrales/diagnóstico por imagen , Servicio de Urgencia en Hospital , Humanos , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: To evaluate the architecture, integration requirements, and execution characteristics of a remote clinical decision support (CDS) service used in a multicenter clinical trial. The trial tested the efficacy of implementing brain injury prediction rules for children with minor blunt head trauma. MATERIALS AND METHODS: We integrated the Epic(®) electronic health record (EHR) with the Enterprise Clinical Rules Service (ECRS), a web-based CDS service, at two emergency departments. Patterns of CDS review included either a delayed, near-real-time review, where the physician viewed CDS recommendations generated by the nursing assessment, or a real-time review, where the physician viewed recommendations generated by their own documentation. A backstopping, vendor-based CDS triggered with zero delay when no recommendation was available in the EHR from the web-service. We assessed the execution characteristics of the integrated system and the source of the generated recommendations viewed by physicians. RESULTS: The ECRS mean execution time was 0.74 ±0.72 s. Overall execution time was substantially different at the two sites, with mean total transaction times of 19.67 and 3.99 s. Of 1930 analyzed transactions from the two sites, 60% (310/521) of all physician documentation-initiated recommendations and 99% (1390/1409) of all nurse documentation-initiated recommendations originated from the remote web service. DISCUSSION: The remote CDS system was the source of recommendations in more than half of the real-time cases and virtually all the near-real-time cases. Comparisons are limited by allowable variation in user workflow and resolution of the EHR clock. CONCLUSION: With maturation and adoption of standards for CDS services, remote CDS shows promise to decrease time-to-trial for multicenter evaluations of candidate decision support interventions.
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Lesiones Encefálicas/diagnóstico , Manejo de Caso , Sistemas de Apoyo a Decisiones Clínicas/estadística & datos numéricos , Registros Electrónicos de Salud/estadística & datos numéricos , Servicio de Urgencia en Hospital/normas , Consulta Remota/estadística & datos numéricos , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , MasculinoRESUMEN
OBJECTIVE: Clinical data warehouses have accelerated clinical research, but even with available open source tools, there is a high barrier to entry due to the complexity of normalizing and importing data. The Office of the National Coordinator for Health Information Technology's Meaningful Use Incentive Program now requires that electronic health record systems produce standardized consolidated clinical document architecture (C-CDA) documents. Here, we leverage this data source to create a low volume standards based import pipeline for the Informatics for Integrating Biology and the Bedside (i2b2) clinical research platform. We validate this approach by creating a small repository at Partners Healthcare automatically from C-CDA documents. MATERIALS AND METHODS: We designed an i2b2 extension to import C-CDAs into i2b2. It is extensible to other sites with variances in C-CDA format without requiring custom code. We also designed new ontology structures for querying the imported data. RESULTS: We implemented our methodology at Partners Healthcare, where we developed an adapter to retrieve C-CDAs from Enterprise Services. Our current implementation supports demographics, encounters, problems, and medications. We imported approximately 17 000 clinical observations on 145 patients into i2b2 in about 24 min. We were able to perform i2b2 cohort finding queries and view patient information through SMART apps on the imported data. DISCUSSION: This low volume import approach can serve small practices with local access to C-CDAs and will allow patient registries to import patient supplied C-CDAs. These components will soon be available open source on the i2b2 wiki. CONCLUSIONS: Our approach will lower barriers to entry in implementing i2b2 where informatics expertise or data access are limited.
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Investigación Biomédica , Continuidad de la Atención al Paciente , Bases de Datos como Asunto , Almacenamiento y Recuperación de la Información , Sistemas de Administración de Bases de Datos , Bases de Datos como Asunto/organización & administración , Humanos , Almacenamiento y Recuperación de la Información/métodos , Uso Significativo , Integración de SistemasRESUMEN
OBJECTIVE: To create a clinical decision support (CDS) system that is shareable across healthcare delivery systems and settings over large geographic regions. MATERIALS AND METHODS: The enterprise clinical rules service (ECRS) realizes nine design principles through a series of enterprise java beans and leverages off-the-shelf rules management systems in order to provide consistent, maintainable, and scalable decision support in a variety of settings. RESULTS: The ECRS is deployed at Partners HealthCare System (PHS) and is in use for a series of trials by members of the CDS consortium, including internally developed systems at PHS, the Regenstrief Institute, and vendor-based systems deployed at locations in Oregon and New Jersey. Performance measures indicate that the ECRS provides sub-second response time when measured apart from services required to retrieve data and assemble the continuity of care document used as input. DISCUSSION: We consider related work, design decisions, comparisons with emerging national standards, and discuss uses and limitations of the ECRS. CONCLUSIONS: ECRS design, implementation, and use in CDS consortium trials indicate that it provides the flexibility and modularity needed for broad use and performs adequately. Future work will investigate additional CDS patterns, alternative methods of data passing, and further optimizations in ECRS performance.
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Sistemas de Apoyo a Decisiones Clínicas , Sistemas de Información en Hospital/organización & administración , Hospitales Pediátricos , Humanos , Internet , Registro Médico Coordinado , Sistemas de Registros Médicos Computarizados/organización & administración , Programas InformáticosRESUMEN
Traditionally, rule interactions are handled at implementation time through rule task properties that control the order in which rules are executed. By doing so, knowledge about the behavior and interactions of decision rules is not captured at modeling time. We argue that this is important knowledge that should be integrated in the modeling phase. In this project, we build upon current work on a conceptual schema to represent clinical knowledge for decision support in the form of if
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Algoritmos , Sistemas de Apoyo a Decisiones Clínicas , Técnicas de Apoyo para la Decisión , Registros Electrónicos de Salud , Internet , Procesamiento de Lenguaje Natural , Vocabulario Controlado , SemánticaRESUMEN
The mushroom Agaricus brasiliensis (sun mushroom), native from the southeast of Brazil, is well known by its medicinal properties that include effects on diabetes, cholesterol levels, and osteoporosis. The antimutagenic effects of A. brasiliensis has been investigated recently and revealed some controversial results depending on the temperature by which the A. brasiliensis tea is obtained. In the present study, we evaluated the effect of the A. brasiliensis extract prepared in two different temperatures, 4°C and 25°C, on the doxorubicin-induced DNA strand breaks and chromosomal aberrations (CAs) in human lymphocytes. The results demonstrated that A. brasiliensis was able to reduce the DXR-induced DNA damage in both temperatures; however, the CA test was more sensitive to demonstrate a better reduction when the cells were treated with an extract obtained at 25°C. A. brasiliensis extract obtained in different temperatures exhibited antigenotoxic and anticlastogenic effects in human lymphocytes.
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Agaricus/química , Antimutagênicos/farmacología , Linfocitos/efectos de los fármacos , Células Cultivadas , Aberraciones Cromosómicas/efectos de los fármacos , Daño del ADN/efectos de los fármacos , HumanosRESUMEN
The Clinical Decision Support Consortium has completed two demonstration trials involving a web service for the execution of clinical decision support (CDS) rules in one or more electronic health record (EHR) systems. The initial trial ran in a local EHR at Partners HealthCare. A second EHR site, associated with Wishard Memorial Hospital, Indianapolis, IN, was added in the second trial. Data were gathered during each 6 month period and analyzed to assess performance, reliability, and response time in the form of means and standard deviations for all technical components of the service, including assembling and preparation of input data. The mean service call time for each period was just over 2 seconds. In this paper we report on the findings and analysis to date while describing the areas for further analysis and optimization as we continue to expand our use of a Services Oriented Architecture approach for CDS across multiple institutions.
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Sistemas de Apoyo a Decisiones Clínicas , Sistemas de Registros Médicos Computarizados , Guías de Práctica Clínica como Asunto , Registros Electrónicos de Salud , Humanos , Internet , Estados Unidos , United States Agency for Healthcare Research and QualityRESUMEN
BACKGROUND: There are several challenges in encoding guideline knowledge in a form that is portable to different clinical sites, including the heterogeneity of clinical decision support (CDS) tools, of patient data representations, and of workflows. METHODS: We have developed a multi-layered knowledge representation framework for structuring guideline recommendations for implementation in a variety of CDS contexts. In this framework, guideline recommendations are increasingly structured through four layers, successively transforming a narrative text recommendation into input for a CDS system. We have used this framework to implement rules for a CDS service based on three guidelines. We also conducted a preliminary evaluation, where we asked CDS experts at four institutions to rate the implementability of six recommendations from the three guidelines. CONCLUSION: The experience in using the framework and the preliminary evaluation indicate that this approach has promise in creating structured knowledge, to implement in CDS systems, that is usable across organizations.
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Inteligencia Artificial , Toma de Decisiones Asistida por Computador , Guías de Práctica Clínica como Asunto , Sistemas de Apoyo a Decisiones Clínicas , Diseño de SoftwareRESUMEN
An important barrier to the widespread dissemination of clinical decision support (CDS) is the heterogeneity of information models and terminologies used across healthcare institutions, health information systems, and CDS resources such as knowledge bases. To address this problem, the Health Level 7 (HL7) Virtual Medical Record project (an open, international standards development effort) is developing community consensus on the clinical information exchanged between CDS engines and clinical information systems. As a part of this effort, the HL7 CDS Work Group embarked on a multinational, collaborative effort to identify a representative set of clinical data elements required for CDS. Based on an analysis of CDS systems from 20 institutions representing 4 nations, 131 data elements were identified as being currently utilized for CDS. These findings will inform the development of the emerging HL7 Virtual Medical Record standard and will facilitate the achievement of scalable, standards-based CDS.
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Sistemas de Apoyo a Decisiones Clínicas , Estándar HL7 , Registros Electrónicos de Salud , Instituciones de Salud , Humanos , Registro Médico Coordinado , Registros Médicos , Sistemas de Registros Médicos ComputarizadosRESUMEN
Creating shareable decision support services is a complex task requiring effort from multiple interdisciplinary role players with a wide variety of experience and expertise. The CDS Consortium research project has developed such a service, defining a multi-layer representation of knowledge and building upon an architectural service design created at Partners Health Care, and is demonstrating its use in both a local and an external institutional setting. The process was iterative, and we encountered unexpected requirements based on decisions made at various points. We report in this paper on challenges we faced while pursuing this research: knowledge representation and modeling, data interchange and standards adoption, the process of getting agreement on content, logistics of integrating into a system that already has multiple CDS interventions, legal issues around privacy and access, inter-team communication and organization.
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Authors evaluated the impact of computerized alerts on the quality of outpatient laboratory monitoring for transplant patients. For 356 outpatient liver transplant patients managed at LDS Hospital, Salt Lake City, this observational study compared traditional laboratory result reporting, using faxes and printouts, to computerized alerts implemented in 2004. Study alerts within the electronic health record notified clinicians of new results and overdue new orders for creatinine tests and immunosuppression drug levels. After implementing alerts, completeness of reporting increased from 66 to >99 %, as did positive predictive value that a report included new information (from 46 to >99 %). Timeliness of reporting and clinicians' responses improved after implementing alerts (p <0.001): median times for clinicians to receive and complete actions decreased to 9 hours from 33 hours using the prior traditional reporting system. Computerized alerts led to more efficient, complete, and timely management of laboratory information.
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Atención Ambulatoria , Sistemas de Información en Laboratorio Clínico , Técnicas de Laboratorio Clínico , Sistemas de Apoyo a Decisiones Clínicas , Trasplante de Hígado , Sistemas Recordatorios , Humanos , Sistemas de Registros Médicos Computarizados , Monitoreo Fisiológico , Calidad de la Atención de SaludRESUMEN
INTRODUCTION: We evaluated the feasibility of using an electronic protocol developed for research use (Research-eProtocol-insulin) for blood glucose management in usual intensive care unit clinical practice. METHODS: We implemented the rules of Research-eProtocol-insulin in the electronic medical record of the Intermountain Healthcare hospital system (Clinical-eProtocol-insulin) for use in usual clinical practice. We evaluated the performance of Clinical-eProtocol-insulin rules in the intensive care units of seven Intermountain Healthcare hospitals and compared this performance with the performance of Research-eProtocol-insulin at the LDS Hospital Shock/Trauma/Respiratory Intensive Care Unit. RESULTS: Clinician (nurse or physician) compliance with computerized protocol recommendations was 95% (of 21,325 recommendations) with Research-eProtocol-insulin and 92% (of 109,458 recommendations) with Clinical-eProtocol-insulin. The blood glucose distribution in clinical practice (Clinical-eProtocol-insulin) was similar to the research use distribution (Research-eProtocol-insulin); however, the mean values (119 mg/dl vs 113 mg/dl) were statistically different (P = 0.0001). Hypoglycemia rates in the research and practice settings did not differ: the percentage of measurements < or =40 mg/dl (0.11% vs 0.1%, P = 0.65) and the percentage of patients with at least one blood glucose < or =40 mg/dl (4.2% vs 3%, P = 0.23) were not statistically significantly different. CONCLUSION: Our electronic blood glucose protocol enabled translation of a research decision-support tool (Research-eProtocol-insulin) to usual clinical practice (Clinical-eProtocol-insulin).
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Chronically anticoagulated patients taking the drug Warfarin require time intensive management and followup processes to avoid complications. The "Chronic Anticoagulation Clinic" (CAC) protocol is a set of production rules that help manage, treat, and follow-up such patients. The CAC protocol has been in regular use at Intermountain Healthcare (Salt Lake City, UT, USA) for over three years. The results demonstrate an improvement on the number of patients with anticoagulation levels within the desired target range. The protocol alerts have a high acceptance rate (83.4%) and were able to help patients remember to collect their next coagulation test. The CAC protocol results show that production rules can improve the management of chronically anticoagulated patients. Additional studies are required to verify if this experience can be transferred to other institutions.
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Anticoagulantes/uso terapéutico , Quimioterapia Asistida por Computador , Warfarina/uso terapéutico , Sistemas de Apoyo a Decisiones Clínicas , Humanos , Relación Normalizada InternacionalRESUMEN
Growing and maintaining a simple and flexible EMR (Electronic Medical Record) becomes a complicated task in light of diverse and distributed legacy data representation, advancing technologies, changes in medical practice and procedure, and changes in data regulation. Utilizing several abstraction mechanisms can simplify application development and maintenance, and provide flexibility for data evolution and migration. Newer applications built on these abstractions can be the beneficiary of slower obsolescence and lower maintenance costs.
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Almacenamiento y Recuperación de la Información/métodos , Sistemas de Información , Sistemas de Registros Médicos Computarizados , Indización y Redacción de Resúmenes , Inteligencia Artificial , Sistemas de Apoyo a Decisiones Clínicas , Humanos , Lenguajes de ProgramaciónRESUMEN
PURPOSE: This report describes an ongoing transition from the HELP Hospital Information System to HELP II, a replacement Health Information System built to manage clinical information captured in a variety of medical settings. The focus of the article is on the medical decision support provided by this system and studied by researchers at the University of Utah and Intermountain Health Care (IHC), a large health care organization in Utah, for many years. METHODS: Select success features of the original HELP system's decision support environment are identified and lessons learned are related. Plans for transferring these features to HELP II are discussed. RESULTS: The article focuses on four features: (1) the importance of easy access to patient data essential for decision support, (2) the commitment to continued measurement and revision of both the logic and the interventional strategy in a decision support application, (3) experience with data mining as a tool for developing decision support tools, and (4) the role of clinical reports in supporting the decision making process.
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Sistemas de Apoyo a Decisiones Clínicas/organización & administración , Sistemas de Información en Hospital/organización & administración , Humanos , Computación en Informática Médica , Sistemas de Atención de Punto , Evaluación de Programas y Proyectos de Salud , Calidad de la Atención de SaludRESUMEN
Um sistema especialista foi avaliado na sua capacidade em detectar infeccções em pacientes pediátricos hospitalizados. O sistema teve uma sensitividade de 100 por cento na detecção de bacteremias e 57 por cento na detecção de infecções cirúrgicas, quando comparado a um "gold-standard".
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Humanos , Masculino , Femenino , Recién Nacido , Lactante , Preescolar , Niño , Adolescente , Sistemas Especialistas , Infección Hospitalaria/epidemiología , Bacteriemia/epidemiología , Infección de la Herida Quirúrgica/epidemiología , Registros MédicosRESUMEN
O estudo apresentado busca a identificação de fatores responsáveis pelo sucesso do programa de pós-graduação em informática Médica, através de questionários enviados aos docentes e alunos. As respostas obtidas são analisadas levando em consideração a evolução histórica do programa e as características do ambiente no qual o programa tem sido oferecido.