Functional status in ICU survivors and out of hospital outcomes: a cohort study

OBJECTIVES: Functional status at hospital discharge may be a risk factor for adverse events among survivors of critical illness. We sought to examine the association between functional status at hospital discharge in survivors of critical care and risk of 90-day all-cause mortality after hospital discharge. DESIGN: Single-center retrospective cohort study. SETTING: Academic Medical Center. PATIENTS: Ten thousand three hundred forty-three adults who received critical care from 1997 to 2011 and survived hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The exposure of interest was functional status determined at hospital discharge by a licensed physical therapist and rated based on qualitative categories adapted from the Functional Independence Measure. The main outcome was 90-day post hospital discharge all-cause mortality. A categorical risk-prediction score was derived and validated based on a logistic regression model of the function grades for each assessment. In an adjusted logistic regression model, the lowest quartile of functional status at hospital discharge was associated with an increased odds of 90-day postdischarge mortality compared with patients with independent functional status (odds ratio, 7.63 [95% CI, 3.83-15.22; p < 0.001]). In patients who had at least 7 days of physical therapy treatment prior to hospital discharge (n = 2,293), the adjusted odds of 90-day postdischarge mortality in patients with marked improvement in functional status at discharge was 64% less than patients with no change in functional status (odds ratio, 0.36 [95% CI, 0.24-0.53]; p < 0.001). CONCLUSIONS: Lower functional status at hospital discharge in survivors of critical illness is associated with increased postdischarge mortality. Furthermore, patients whose functional status improves before discharge have decreased odds of postdischarge mortality.L30 TR001257 - NCATS NIH HH

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting

Background Experts suggest that formulary alerts at the time of medication order entry are the most effective form of clinical decision support to automate formulary management. Objective Our objectives were to quantify the frequency of inappropriate nonformulary medication (NFM) alert overrides in the inpatient setting and provide insight on how the design of formulary alerts could be improved. Methods Alert overrides of the top 11 (n = 206) most-utilized and highest-costing NFMs, from January 1 to December 31, 2012, were randomly selected for appropriateness evaluation. Using an empirically developed appropriateness algorithm, appropriateness of NFM alert overrides was assessed by 2 pharmacists via chart review. Appropriateness agreement of overrides was assessed with a Cohen’s kappa. We also assessed which types of NFMs were most likely to be inappropriately overridden, the override reasons that were disproportionately provided in the inappropriate overrides, and the specific reasons the overrides were considered inappropriate. Results Approximately 17.2% (n = 35.4/206) of NFM alerts were inappropriately overridden. Non-oral NFM alerts were more likely to be inappropriately overridden compared to orals. Alerts overridden with “blank” reasons were more likely to be inappropriate. The failure to first try a formulary alternative was the most common reason for alerts being overridden inappropriately. Conclusion Approximately 1 in 5 NFM alert overrides are overridden inappropriately. Future research should evaluate the impact of mandating a valid override reason and adding a list of formulary alternatives to each NFM alert; we speculate these NFM alert features may decrease the frequency of inappropriate overrides

Organizing Vision and Local IS Practices: A France - U.S. Comparison

In their organizing vision model, Swanson and Ramiller called for more research on the relationship between interorganizational authorized (legitimated) discourse on IT and organizational practices. In this paper, the research question is focused on national differences in the way cross-organizational discourses interact with local practices. The methodology used includes the identification of so-called authorized ideas through an analysis of both French and U.S. publications (using thematic and lexicometric analysis), as well as IT forums, from 1999 to 2003. This analysis is then merged with an overview of French and American case studies. The results demonstrate strong differences in the OV production systems, as well as in organizational behaviour\u27s reaction to cross-organizational discourse

A Fit between Clinical Workflow and Health Care Information Systems: Not waiting for Godot but making the journey

Health care has long suffered from inefficiencies due to the fragmentation of patient care information and the lack of coordination between health professionals [1]. Health care information systems (HISs) have been lauded as tools to remedy such inefficiencies [2, 3]. The primary idea behind the support of their implementation in health care is that these systems support clinical workflow and thereby decrease medical errors [2]. However, their introduction to health care settings have been accompanied by a transformation of the way their primary users, care providers, carry out clinical tasks and establish or maintain work relationships [4]. Studies have shown that these transformations have not always been productive [5, 6]

Information Systems and Healthcare XXXI: Improving Infection Control Process Efficiency to Reduce Hospital Acquired Infections

Inconsistent and incomplete information due to the diversity of isolated information systems is one of the major problems information technology faces in the healthcare sector. The insufficient integration of actors results in delays in clinical processes. However, due to strict constraints in health care such as health regulations, clinical processes cannot be modified freely. The approach of this work is to apply the less radical principles of Business Process Management to medical information systems to provide reliable and timely access to relevant patient information and to decrease process lead time. In particular, this work outlines the impact of optimization for administrative processes. To substantiate our research, we performed a case study in collaboration with a healthcare provider and a regional healthcare facility in the U.S. We report on the workflow implementation of a clinical infection control process which integrates disparate systems and automates clinical decision making according to clinical knowledge. The post-metrics clearly emphasize the capability of Business Process Management to improve the integration of information, increase the quality of patient care, reduce health worker\u27s stress, and ease costs of treatment by significantly shortening process lead time. We conclude with a generalization of the results for other healthcare enterprises

MS

thesisHealth information systems are networks of computers employed by health care enterprises to facilitate the delivery of their health care product. Computers originally entered the medical domain solely as tools aimed at the business functions of the hospital. Having demonstrated their utility in this area, computers were perceived by certain innovators to have usefulness in the clinical domain. As clinical computer applications were successfully developed and implemented, they have over time been merged together into systems offering multiple areas of functionality directly impacting the clinical aspects of health care delivery. Such health information systems have now assumed major importance in the provision of health care in a complex medical environment. Although the focus of substantial investment for development and implementation, relatively little work has been done to assess the value of such health information systems. The business information technology literature and the medical informatics literature each include only a small number of published reports examining the value question in an incomplete manner. No generally accepted valuation strategy has been developed for information systems in either the business or health care domains. Several valuation methods with potential applicability to health information systems have evolved: cost-effectiveness / cost- benefit analysis, return on investment, information economics, measurement systems, the Strassmann approach, the Japanese approach, and the strategic value approach. None of these valuation strategies is clearly superior; each has different strengths and weaknesses. A matrix comparing these strategies on the bases of explicitness and ease of implementation is proposed. Intermountain Health Care (IHC) has been instrumental in the development of health information systems and a leader in the application of such technology in clinical health care delivery. IHC's HELP system has played a seminal role as a catalyst to the development of the health information system industry. Although both historically and functionally important, detailed financial information regarding HELP'S origins and implementation no longer exists. Current IHC budget information demonstrates the major financial commitment underway within this health care enterprise totaling approximately $157 million over the last decade and with additional expenditures of$47 to $61 million projected annually through fiscal year 2004. The complex budgetary relationships between HELP and the other health information systems at LDS Hospital further obscure the magnitude of the information technology investment within this institution. Benefits of health information systems are potentially most substantial within the domain of clinical integration. IHC has not implemented any formal valuation strategy for its health information systems, but the ad hoc measurement systems valuation approach applied to date is practical, flexible, and the most appropriate of the available systems. Adequate valuation of health information systems cannot readily be achieved given the existing traditional hierarchical accounting structure; an alternative accounting framework patterned after a relational database is proposed