Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Oculometric screening for traumatic brain injury in veterans

Reissued 21 Aug 2017 with correction to thesis advisor's name.A collaborative project between Naval Postgraduate School (NPS), Veterans Affairs Palo Alto Health Care System (VAPAHCS), Defense and Veterans Brain Injury Center (DVBIC), and neuroFit Inc., was developed to: 1) assess the efficacy of the Comprehensive Oculometric Behavioral Response Assessment (COBRA) as a screening method for mild-to-moderate Traumatic Brain Injury (TBI) in veterans, and 2) evaluate the usability of the neuroFit Oculometric Neurological Examination (ONE) device in military medical facilities. COBRA metrics used to characterize oculometric signs associated with TBI came from two published samples: a 41-subject control sample and a 34-subject civilian TBI sample comprised of mild (loss of consciousness (LOC)24 h) TBIs. The control sample was compared to the eight-subject veteran TBI sample (age range: 27–55 years; 8 males) from the VAPAHCS, comprised of mild (n=7) and moderate (n=1) TBI diagnoses and posttraumatic amnesia (PTA) (n=4). Results demonstrated a significant (p = .02) difference between the control and veteran TBI samples. COBRA metrics accurately detected TBIs at a rate of 77%. Results indicate the COBRA method is viable for TBI screening in military medical facilities and may be suitable for diagnosing chronic visual problems related to mild and moderate TBI.http://archive.org/details/oculometricscree1094555550Captain, United States ArmyApproved for public release; distribution is unlimited

Finding a Cure: The Case for Regulation and Oversight of Electronic Health Record Systems

In the foreseeable future, it is likely that the familiar, paper-based patient medical files will become a thing of the past. On April 26, 24, President George W. Bush announced a plan to ensure that all Americans\u27 health records are computerized within ten years and to establish a National Health Information Network. Many advocates are enthusiastically promoting the adoption of health information technology (HIT) and electronic health record (HER) systems as a means to improve U.S. health care. HER systems often not only serve as record-keeping systems, but also have multiple capabilities, including drug ordering, decision support, alerts concerning patient allergies and potential drug interactions, reminders concerning routine tests, and various treatment management and data analysis tools. Because these capabilities require sophisticated software, significant risks of software failure exist, which can lead to life-threatening medical errors. Thus far, scholars have not provided a comprehensive assessment of the benefits and risks of this complex technology and evaluated the need for careful regulatory oversight akin to that required, in principle, by the FDA for life-critical medical devices. This paper begins to fill that gap. It analyzes HER systems from both legal and technical perspectives and focuses on how the law can be used as a tool to promote HIT. It is the first law journal article to provide an extensive proposal for regulations to maximize the technology\u27s benefits and reliability. We argue that the advantages of HER systems will outweigh their risks only if these systems are developed and maintained with rigorous adherence to best software engineering and medical informatics practices. To ensure that these goals are achieved, regulatory intervention is needed. The paper carefully delineates recommendations that address the questions of who should regulate HER systems and how they should be regulated, including their approval and continual monitoring. It also proposes requirements for several significant features, including decision support mechanisms, audit trails, and interoperability. Because HER systems are safety-critical, the public\u27s health and welfare will depend upon their effective oversight

Finding a Cure: The Case for Regulation and Oversight of Electronic Health Record Systems

In the foreseeable future, it is likely that the familiar, paper-based patient medical files will become a thing of the past. On April 26, 24, President George W. Bush announced a plan to ensure that all Americans\u27 health records are computerized within ten years and to establish a National Health Information Network. Many advocates are enthusiastically promoting the adoption of health information technology (HIT) and electronic health record (HER) systems as a means to improve U.S. health care. HER systems often not only serve as record-keeping systems, but also have multiple capabilities, including drug ordering, decision support, alerts concerning patient allergies and potential drug interactions, reminders concerning routine tests, and various treatment management and data analysis tools. Because these capabilities require sophisticated software, significant risks of software failure exist, which can lead to life-threatening medical errors. Thus far, scholars have not provided a comprehensive assessment of the benefits and risks of this complex technology and evaluated the need for careful regulatory oversight akin to that required, in principle, by the FDA for life-critical medical devices. This paper begins to fill that gap. It analyzes HER systems from both legal and technical perspectives and focuses on how the law can be used as a tool to promote HIT. It is the first law journal article to provide an extensive proposal for regulations to maximize the technology\u27s benefits and reliability. We argue that the advantages of HER systems will outweigh their risks only if these systems are developed and maintained with rigorous adherence to best software engineering and medical informatics practices. To ensure that these goals are achieved, regulatory intervention is needed. The paper carefully delineates recommendations that address the questions of who should regulate HER systems and how they should be regulated, including their approval and continual monitoring. It also proposes requirements for several significant features, including decision support mechanisms, audit trails, and interoperability. Because HER systems are safety-critical, the public\u27s health and welfare will depend upon their effective oversight

Combining Free Text and Structured Electronic Medical Record Entries to Detect Acute Respiratory Infections

The electronic medical record (EMR) contains a rich source of information that could be harnessed for epidemic surveillance. We asked if structured EMR data could be coupled with computerized processing of free-text clinical entries to enhance detection of acute respiratory infections (ARI).A manual review of EMR records related to 15,377 outpatient visits uncovered 280 reference cases of ARI. We used logistic regression with backward elimination to determine which among candidate structured EMR parameters (diagnostic codes, vital signs and orders for tests, imaging and medications) contributed to the detection of those reference cases. We also developed a computerized free-text search to identify clinical notes documenting at least two non-negated ARI symptoms. We then used heuristics to build case-detection algorithms that best combined the retained structured EMR parameters with the results of the text analysis.An adjusted grouping of diagnostic codes identified reference ARI patients with a sensitivity of 79%, a specificity of 96% and a positive predictive value (PPV) of 32%. Of the 21 additional structured clinical parameters considered, two contributed significantly to ARI detection: new prescriptions for cough remedies and elevations in body temperature to at least 38°C. Together with the diagnostic codes, these parameters increased detection sensitivity to 87%, but specificity and PPV declined to 95% and 25%, respectively. Adding text analysis increased sensitivity to 99%, but PPV dropped further to 14%. Algorithms that required satisfying both a query of structured EMR parameters as well as text analysis disclosed PPVs of 52-68% and retained sensitivities of 69-73%.Structured EMR parameters and free-text analyses can be combined into algorithms that can detect ARI cases with new levels of sensitivity or precision. These results highlight potential paths by which repurposed EMR information could facilitate the discovery of epidemics before they cause mass casualties

Reducing Suicide by Providing Cognitive Behavioral Therapy for Suicide Prevention

Veteran suicide is a serious and persistent national problem, which demands an effective treatment intervention. This Evidence-Based Practice project (EBP) addressed the question: Do patients with a psychiatric in-patient diagnosis of suicide ideation, who after discharge self-elect outpatient Cognitive Behavioral Therapy-Suicide Prevention (CBT-SP) treatment over a 6-week time frame, reduce the likelihood of hospital readmission for suicidal ideation vs. patients who decline CBT-SP treatment and elect Treatment as Usual (TAU)? The literature is prolific in validating that CBT-SP is successful in determining the effectiveness of CBT-SP vs. TAU in reducing suicidal behaviors in adults. Hospital readmission data were collected on both the CBT-SP and the TAU groups. The CBT-SP group collected a further measure utilizing the Quality of Life (QOL) Scale pre and post CBT-SP group intervention. Demographic variables of age, sex, and homelessness were compared to assess variability between the two groups. The CBT-SP and the TAU groups were compared for rehospitalization utilizing the Fisher Exact Test, which was statistically significant

Complex Care Management Program Overview

This report includes brief updates on various forms of complex care management including: Aetna - Medicare Advantage Embedded Case Management ProgramBrigham and Women's Hospital - Care Management ProgramIndependent Health - Care PartnersIntermountain Healthcare and Oregon Health and Science University - Care Management PlusJohns Hopkins University - Hospital at HomeMount Sinai Medical Center -- New York - Mount Sinai Visiting Doctors Program/ Chelsea-Village House Calls ProgramsPartners in Care Foundation - HomeMeds ProgramPrinceton HealthCare System - Partnerships for PIECEQuality Improvement for Complex Chronic Conditions - CarePartner ProgramSenior Services - Project Enhance/EnhanceWellnessSenior Whole Health - Complex Care Management ProgramSumma Health/Ohio Department of Aging - PASSPORT Medicaid Waiver ProgramSutter Health - Sutter Care Coordination ProgramUniversity of Washington School of Medicine - TEAMcar

Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication

BACKGROUND: Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response. METHODS: Using both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention. RESULTS: Data from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p\u3c0.01) and was sustained at month 4 following the intervention. CONCLUSION: Electronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems