Assay of contact photosensitivity to musk ambrette in guinea pigs.

This study reports the induction of contact photodermatitis to musk ambrette, 2-methoxy-3,5-dinitro-4-methyl-t-butylbenzene, in guinea pigs. Photoallergic contact dermatitis was assayed using 2 alternative induction methods. Successful photosensitization was achieved only when the nuchal skin was stripped with scotch tape before application of musk ambrette and ultraviolet radiation. Induction methods utilizing nonstripped nuchal skin which induce photosensitivity to potent photoallergens were ineffective for musk ambrette. Phtotoxicity tests to musk ambrette at concentrations between 1 and 50% and a dose of 10.2 joules/cm2 from "Black Light" fluorescent tubes were all negative. Under identical irradiation conditions, anthracene at 0.9% and 8-methoxypsoralen at 1% were consistently positive. The mechanism of photosensitivity to musk ambrette appears to be photoallergic rather than phototoxic. The requirement for skin abrasion to induce photosensitization parallels the clinical reports of photosensitivity to musk ambrette in man.

Evaluation of a data warehouse in an academic health sciences center.

OBJECTIVES: The Clinical data repository (CDR) at the University of Virginia Health System is a data warehouse that provides direct access to data for clinical research and effective decision making. We undertook an evaluation of the CDR to understand factors affecting its adoption. DESIGN: We used a theoretical framework that is based on diffusion of innovation theory. Building on validated survey instruments, we developed a questionnaire and conducted interviews of key executive leaders. Fifty-three individuals with logon ids to the CDR completed our questionnaire. Twelve executive leaders were interviewed. MEASUREMENTS: The outcome variables were the initial and continued use of the CDR. Independent variables included attributes suggested by diffusion theory (i.e. relative advantage, complexity), knowledge and skills expected to correlate with computer usage, and the influence of communication channels. RESULTS: Our overall response rate was 82%. We identified characteristics of users associated with the initial decision to use the CDR. Compatibility with an individual's skills and work style was associated strongly with satisfaction and continued use. Secondly, the importance of organizational culture and the need for data was illuminated by management interviews. CONCLUSIONS: We have shown that diffusion of innovation theory can be used to help understand factors contributing to the success of a data warehouse in a healthcare setting. Our results suggest areas for future research and inquiry as the CDR evolves.

Case study: a data warehouse for an academic medical center.

The clinical data repository (CDR) is a frequently updated relational data warehouse that provides users with direct access to detailed, flexible, and rapid retrospective views of clinical, administrative, and financial patient data for the University of Virginia Health System. This article presents a case study of the CDR, detailing its five-year history and focusing on the unique role of data warehousing in an academic medical center. Specifically, the CDR must support multiple missions, including research and education, in addition to administration and management. Users include not only analysts and administrators but clinicians, researchers, and students.

Adding value to clinical data by linkage to a public death registry.

We describe the methodology and impact of merging detailed statewide mortality data into the master patient index tables of the clinical data repository (CDR) of the University of Virginia Health System (UVAHS). We employ three broadly inclusive linkage passes (designed to result in large numbers of false positives) to match the patients in the CDR to those in the statewide files using the following criteria: a) Social Security Number; b) Patient Last Name and Birth Date; c) Patient Last Name and Patient First Name. The results from these initial matches are refined by calculation and assignment of a total score comprised of partial scores depending on the quality of matching between the various identifiers. In order to validate our scoring algorithm, we used those patients known to have died at UVAHS over the eight year period as an internal control. We conclude that we are able to update our CDR with 97% of the deaths from the state source using this scheme. We illustrate the potential of the resulting system to assist caregivers in identification of at-risk patient groups by description of those patients in the CDR who were found to have committed suicide. We suggest that our approach represents an efficient and inexpensive way to enrich hospital data with important outcomes information.

Physician beliefs about the impact of meaningful use of the EHR: a cross-sectional study.

BACKGROUND: As adoption and use of electronic health records (EHRs) grows in the United States, there is a growing need in the field of applied clinical informatics to evaluate physician perceptions and beliefs about the impact of EHRs. The meaningful use of EHR incentive program provides a suitable context to examine physician beliefs about the impact of EHRs. OBJECTIVE: Contribute to the sparse literature on physician beliefs about the impact of EHRs in areas such as quality of care, effectiveness of care, and delivery of care. METHODS: A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who were preparing to qualify for the meaningful use of EHR incentive program. RESULTS: Of the 1,797 physicians at both AMCs who were preparing to qualify for the incentive program, 967 completed the survey for an overall response rate of 54%. Only 23% and 27% of physicians agreed or strongly agreed that meaningful use of the EHR will help them improve the care they personally deliver and improve quality of care respectively. Physician specialty was significantly associated with beliefs; e.g., 35% of primary care physicians agreed or strongly agreed that meaningful use will improve quality of care compared to 26% of medical specialists and 21% of surgical specialists (p=0.009). Satisfaction with outpatient EHR was also significantly related to all belief items. CONCLUSIONS: Only about a quarter of physicians in our study responded positively that meaningful use of the EHR will improve quality of care and the care they personally provide. These findings are similar to and extend findings from qualitative studies about negative perceptions that physicians hold about the impact of EHRs. Factors outside of the regulatory context, such as physician beliefs, need to be considered in the implementation of the meaningful use of the EHR incentive program.

Leveraging information technology to improve quality and safety.

OBJECTIVES: To examine five areas that we will be central to informatics research in the years to come: changing provider behavior and improving outcomes, secondary uses of clinical data, using health information technology to improve patient safety, personal health records, and clinical data exchange. METHODS: Potential articles were identified through Medline and Internet searches and were selected for inclusion in this review by the authors. RESULTS: We review highlights from the literature in these areas over the past year, drawing attention to key points and opportunities for future work. CONCLUSIONS: Informatics may be a key tool for helping to improve patient care quality, safety, and efficiency. However, questions remain about how best to use existing technologies, deploy new ones, and to evaluate the effects. A great deal of research has been done on changing provider behavior, but most work to date has shown that process benefits are easier to achieve than outcomes benefits, especially for chronic diseases. Use of secondary data (data warehouses and disease registries) has enormous potential, though published research is scarce. It is now clear in most nations that one of the key tools for improving patient safety will be information technology--many more studies of different approaches are needed in this area. Finally, both personal health records and clinical data exchange appear to be potentially transformative developments, but much of the published research to date on these topics appears to be taking place in the U.S.--more research from other nations is needed.

Evaluation of a data warehouse in an academic health sciences center.

A data warehouse can provide significant benefits to a health care organization if successfully designed and implemented. The Clinical Data Repository (CDR) at the University of Virginia Health Sciences Center improves access to needed data for clinical research and effective decision making at many levels of the organization. We conducted an evaluation of the CDR using a survey questionnaire and interviews of key executive leaders. Our results suggest factors that influence the initial decision to use an information resource, examine the impact of communication channels, and highlight key issues that determine the continued use and ultimate success of a healthcare data warehouse.

Using a clinical data repository to estimate the frequency and costs of adverse drug events.

As a result of increased attention to medical errors, many institutions are contemplating increased use of information technology and clinical decision support. We conducted a retrospective analysis to estimate the frequency and cost of adverse drug events (ADEs) for inpatients at the University of Virginia. Applying published criteria for the detection of potential adverse events, we used a clinical data warehouse to identify patients and cases with potential ADEs. Again using published criteria, we then estimated the actual number of adverse drug events and preventable adverse drug events, as well as their attributable costs and excess length of stay. Our results showed a higher estimate (10.4-11.5 events per 100 admissions) for ADEs than seen in the ADE Prevention Study, highlighting the importance of considering the generalizability of published ADE studies to other settings. Our analysis demonstrates that retrospective analysis can be an efficient and powerful technique to evaluate rules and criteria used to detect ADEs and to assess their impact.

Outcomes research using the electronic patient record: Beth Israel Hospital's experience with anticoagulation.

Using data captured as part of the routine care of outpatients taking the oral anticoagulant warfarin, we described variation in recording reasons for anticoagulation, selecting target International Normalized Ratio (INR) ranges, and performing coagulation blood tests. Laboratory results were directly captured by or entered into an Anticoagulation Flowsheet, a computer program which is fully integrated with our Online Medical Record (OMR). We studied the 177 patients with flowsheets between October 1993 and January 1995. 90% had a reason for anticoagulation entered; 29 different target INR ranges were entered. For patients with a target INR of 2.0-3.0, the mean number of weeks between blood tests, after a test which was in range, was three weeks (standard deviation 1.7 weeks, range one to twelve weeks). We conclude that routinely collected data contained in an electronic patient record (EPR) can be a rich resource for describing and evaluating clinical practice. We also address several limitations to using EPR data: validity of EPR information, lack of coded information, and imperfect capture of clinician thought processes.

Making effective referrals: a knowledge-management approach.

Patients and physicians often choose specially consultants with only limited knowledge of the available options. Access to information about specialists that was directly relevant to patient and clinician preferences could improve the effectiveness of the referral process. We have developed a prescriptive representation of the process of selecting consultants. This "referral map," based on decision theory, uses patient and provider preferences elicited through a literature review and interviews with physicians and provides a formal framework for representing referral knowledge and for evaluating referral options. Our method suggests that the goals and processes of selecting consultants can be managed more systematically using explicit repositories. Such systematic management promises to have a beneficial impact on the delivery of health care, as well as on patient satisfaction.