Improving Allergy Documentation: A Retrospective Electronic Health Record System-Wide Patient Safety Initiative.

OBJECTIVES: Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been reported. The goal of this initiative was to systematically reduce free-text allergen entries in the EHR allergy module. METHODS: We assessed free-text allergy entries in a commercial EHR used at a multihospital integrated health care system in the greater Boston area. Using both manual and automated methods, a multidisciplinary consensus group prioritized high-risk and frequently used free-text allergens for conversion to coded entries, added new allergen entries, and deleted duplicate allergen entries. Environmental allergies were moved to the patient problem list. RESULTS: We identified 242,330 free-text entries, which included a variety of environmental allergies (42%), food allergies (18%), contrast media allergies (13%), "no known allergy" (12%), drug allergies (2%), and "no contrast allergy" (2%). Most free-text entries were entered by medical assistants in ambulatory settings (34%) and registered nurses in perioperative settings (20%). We remediated a total of 52,206 free-text entries with automated methods and 79,578 free-text entries with manual methods. CONCLUSIONS: Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety. Additional strategies are required to completely eliminate free-text allergy entry, and establish systematic, consistent, and safe guidelines for documenting allergies.

Leveraging Quality Improvement Science to Reduce C. difficile Infections in a Community Hospital.

BACKGROUND: The most common infection acquired in US hospitals is Clostridium difficile, which can lead to protracted diarrhea, severe abdominal cramping, and infectious colitis and an attributable mortality of 6.5%. The mortality associated with C. difficile is of major clinical importance. The best strategy to prevent such infections is an open question. METHODS: A multiyear quality improvement initiative was performed in our community hospital to determine where hospitals should focus their resources to achieve sustainable reductions in hospital-acquired C. difficile infection (CDI). Quality improvement methodology was used to evaluate the impact of sequential interventions in environmental cleaning, infection prevention, and antibiotic stewardship over time. RESULTS: After four years, hospital-acquired CDI declined 55.5%, from 12.2 to 5.4 cases/10,000 patient-days (Poisson rate test, p = 0.002). High-risk antibiotic use declined 88.1%, from 63.7 to 7.6 days on treatment/1,000 patient-days (Student's t-test, p < 0.001). The highest-impact intervention was stewardship on diagnostics and high-risk antibiotics using home-grown decision support tools. CONCLUSION: Translating scientific evidence into clinical practice using quality improvement methods led to sustained reductions in C. difficile transmission and identified high-risk antibiotics and diagnostics as key leverage points.

The water relations and xylem attributes of albino redwood shoots (Sequioa sempervirens (D. Don.) Endl.).

Plants that lack chlorophyll are rare and typically restricted to holoparasites that obtain their carbon, water and mineral resources from a host plant. Although not parasites in the traditional sense, albino foliage, such as the sprouts that sometimes develop from redwood tree trunks, are comparable in function. They occur sporadically, and can reach the size of shrubs and in rare cases, trees. Albino redwoods are interesting because in addition to their reduced carbon resources, the absence of chloroplasts may impede proper stomatal function, and both aspects may have upstream consequences on water transport and xylem quality. We examined the water relations, water transport and xylem anatomical attributes of albino redwoods and show that similar to achlorophyllous and parasitic plants, albino redwoods have notably higher stomatal conductance than green sprouts. Given that stem xylem tracheid size as well as water transport efficiency are nearly equivalent in both albino and green individuals, we attribute the increased leaf water loss in albino sprouts to lower leaf to xylem area ratios, which favour improved hydration relative to green sprouts. The stems of albino redwoods were more vulnerable to drought-induced embolism than green stems, and this was consistent with the albino's weaker tracheids, as characterized by wall thickness to lumen diameter measures. Our results are both complementary and consistent with previous research on achlorophyllous plants, and suggest that the loss of stomatal control and photosynthetic capacity results in substantial vascular and anatomical adjustments.

Does electronic stewardship work?

Faced with national requirements to promote antimicrobial stewardship and reduce drug-resistant infections, community hospitals are challenged to make the best use of existing resources. Eighteen months after building antibiotic decision support into our electronic order platform, high-risk antibiotic use decreased by 83% (P < .001) at our community hospital. Hospital-acquired Clostridium difficile infections declined 24% (P = .07).

Impact of vendor computerized physician order entry on patients with renal impairment in community hospitals.

BACKGROUND: Adverse drug events (ADEs) are common among hospitalized patients with renal impairment. OBJECTIVE: To determine whether computerized physician order entry (CPOE) systems with clinical decision support capabilities reduce the frequency of renally related ADEs in hospitals. DESIGN, SETTING, AND PATIENTS: Quasi-experimental study of 1590 adult patients with renal impairment who were admitted to 5 community hospitals in Massachusetts from January 2005 to September 2010, preimplementation and postimplementation of CPOE. INTERVENTION: Varying levels of clinical decision support, ranging from basic CPOE only (sites 4 and 5), rudimentary clinical decision support (sites 1 and 2), and advanced clinical decision support (site 3). MEASUREMENTS: Primary outcome was the rate of preventable ADEs from nephrotoxic and/or renally cleared medications. Similarly, secondary outcomes were the rates of overall ADEs and potential ADEs. KEY RESULTS: There was a 45% decrease in the rate of preventable ADEs following implementation (8.0/100 vs 4.4/100 admissions; P < 0.01), and the impact was related to the level of decision support. Basic CPOE was not associated with any significant benefit (4.6/100 vs 4.3/100 admissions; P = 0.87). There was a nonsignificant decrease in preventable ADEs with rudimentary clinical decision support (9.1/100 vs 6.4/100 admissions; P = 0.22). However, substantial reduction was seen with advanced clinical decision support (12.4/100 vs 0/100 admissions; P = 0.01). Despite these benefits, a significant increase in potential ADEs was found for all systems (55.5/100 vs 136.8/100 admissions; P < 0.01). CONCLUSION: Vendor-developed CPOE with advanced clinical decision support can reduce the occurrence of preventable ADEs but may be associated with an increase in potential ADEs.

Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision support.

BACKGROUND: In-hospital adverse events are a major cause of morbidity and mortality and represent a major cost burden to health care systems. A study was conducted to evaluate the return on investment (ROI) for the adoption of vendor-developed computerized physician oder entry (CPOE) systems in four community hospitals in Massachusetts. METHODS: Of the four hospitals, two were under one management structure and implemented the same vendor-developed CPOE system (Hospital Group A), while the other two were under a second management structure and implemented another vendor-developed CPOE system (Hospital Group B). Cost savings were calculated on the basis of reduction in preventable adverse drug event (ADE) rates as measured previously. ROI, net cash flow, and the breakeven point during a 10-year cost-and-benefit model were calculated. At the time of the study, none of the participating hospitals had implemented more than a rudimentary decision support system together with CPOE. RESULTS: Implementation costs were lower for Hospital Group A than B ($7,130,894 total or $83/admission versus $19,293,379 total or $113/admission, respectively), as were preventable ADE-related avoided costs ($7,937,651 and $16,557,056, respectively). A cost-benefit analysis demonstrated that Hospital Group A had an ROI of 11.3%, breaking even on the investment eight years following implementation. Hospital Group B showed a negative return, with an ROI of -3.1%. CONCLUSIONS: Adoption of vendor CPOE systems in community hospitals was associated with a modest ROI at best when applying cost savings attributable to prevention of ADEs only. The modest financial returns can beattributed to the lack of clinical decision support tools.

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool.

OBJECTIVE: The Leapfrog CPOE evaluation tool has been promoted as a means of monitoring computerized physician order entry (CPOE). We sought to determine the relationship between Leapfrog scores and the rates of preventable adverse drug events (ADE) and potential ADE. MATERIALS AND METHODS: A cross-sectional study of 1000 adult admissions in five community hospitals from October 1, 2008 to September 30, 2010 was performed. Observed rates of preventable ADE and potential ADE were compared with scores reported by the Leapfrog CPOE evaluation tool. The primary outcome was the rate of preventable ADE and the secondary outcome was the composite rate of preventable ADE and potential ADE. RESULTS: Leapfrog performance scores were highly related to the primary outcome. A 43% relative reduction in the rate of preventable ADE was predicted for every 5% increase in Leapfrog scores (rate ratio 0.57; 95% CI 0.37 to 0.88). In absolute terms, four fewer preventable ADE per 100 admissions were predicted for every 5% increase in overall Leapfrog scores (rate difference -4.2; 95% CI -7.4 to -1.1). A statistically significant relationship between Leapfrog scores and the secondary outcome, however, was not detected. DISCUSSION: Our findings support the use of the Leapfrog tool as a means of evaluating and monitoring CPOE performance after implementation, as addressed by current certification standards. CONCLUSIONS: Scores from the Leapfrog CPOE evaluation tool closely relate to actual rates of preventable ADE. Leapfrog testing may alert providers to potential vulnerabilities and highlight areas for further improvement.

The effect of training on the use of tobacco-use cessation guidelines in dental settings.

BACKGROUND: An increase in the number of dentists conducting tobacco-use cessation treatment is needed. The authors assessed the effects of high-intensity training (HIT) or low-intensity training (LIT) and reimbursement on general dentists' tobacco-use-related attitudes and treatment behaviors. METHODS: The authors randomly selected 265 dentists in three states and assigned them to one of five groups: HIT workshop groups with and without tobacco-use cessation counseling reimbursement, LIT mailed self-study groups with and without reimbursement or a control group. Outcomes at follow-up were dentists' self-reported tobacco-use-related attitudes and behaviors and patients' reports of dentists' behaviors. RESULTS: Significantly more dentists in the intervention groups reported having positive attitudes and behaviors at follow-up than did dentists in the control group. Dentists in the HIT groups, however, reported assessing patients' willingness to quit and assisting them with the quitting process significantly more often than did dentists in the LIT groups. Significantly more patients of dentists in the intervention groups who used tobacco reported receiving advice and assistance from their dentists than did patients of dentists in the control group. Adding reimbursement to HIT or LIT conditions did not provide additional intervention effect. CONCLUSION: Dentists trained by means of a workshop or self-study program used components of a recommended guideline more frequently and felt more positive toward tobacco-use cessation counseling than did dentists in the control group. CLINICAL IMPLICATIONS: Although the workshop training was more successful than the self-study training, the latter's reach among dentists could have a more significant public health impact. The effect of reimbursement needs further study.

Impact of vendor computerized physician order entry in community hospitals.

BACKGROUND: It is uncertain if computerized physician order entry (CPOE) systems are effective at reducing adverse drug event (ADE) rates in community hospitals, where mainly vendor-developed applications are used. OBJECTIVE: To evaluate the impact of vendor CPOE systems on the frequency of ADEs. DESIGN AND PATIENTS: Prospective before-and-after study conducted from January 2005 to September 2010 at five Massachusetts community hospitals. Participants were adults admitted during the study period. A total of 2,000 charts were reviewed for orders, medication lists, laboratory reports, admission histories, notes, discharge summaries, and flow sheets. MAIN MEASURES: The primary outcome measure was the rate of preventable ADEs. Rates of potential ADEs and overall ADEs were secondary outcomes. KEY RESULTS: The rate of preventable ADEs decreased following implementation (10.6/100 vs. 7.0/100 admissions; p = 0.007) with a similar effect observed at each site. However, the associated decrease in preventable ADEs was balanced against an increase in potential ADEs (44.4/100 vs. 57.5/100 admissions; p < 0.001). We observed a reduction of 34.0% for preventable ADEs, but an increase of 29.5% in potential ADEs following implementation. The overall rate of ADEs increased (14.6/100 vs. 18.7/100 admissions; p = 0.03), which was driven by non-preventable events (4.0/100 vs. 11.7/100 admissions; p < 0.001). CONCLUSIONS: Adoption of vendor CPOE systems was associated with a decrease in the preventable ADE rate by a third, although the rates of potential ADEs and overall ADEs increased. Our findings support the use of vendor CPOE systems as a means to reduce drug-related injury and harm. The potential ADE rate could be reduced by making refinements to the vendor applications and their associated decision support.

Linking operating margin to payer contracting.

Hospital performance is driven by the revenue generated through paver contracts--and hospitals must demand the contracts they need in order to meet their margin.