Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain

Abstract Background Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients. Methods Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools. Results The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools. Conclusions Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described provide a model for development of other DSSs that translate written guidelines into actionable, real-time clinical recommendations.http://deepblue.lib.umich.edu/bitstream/2027.42/78267/1/1748-5908-5-26.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/2/1748-5908-5-26.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/3/1748-5908-5-26-S3.TIFFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/4/1748-5908-5-26-S2.TIFFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/5/1748-5908-5-26-S1.TIFFPeer Reviewe

Recommendations to the Social Security Administration on the Design of the Mental Health Treatment Study

Many beneficiaries with mental illness who have a strong desire to work nevertheless continue to seek the protection and security of disability benefits, not only because of the income such benefits provide but also for the health care coverage that comes with it. Further complicating matters is that few jobs available to people with mental illnesses have mental health care coverage, forcing individuals to choose between employment and access to care. These barriers, coupled with the limited treatment options and negative employer attitudes and even discrimination when it comes to employing people with serious metal illness, help "explain" the very rates of low labor force participation among people with psychiatric disabilities

Computer-Assisted versus Oral-and-Written History Taking for the Prevention and Management of Cardiovascular Disease: a Systematic Review of the Literature

Background and objectives: CVD is an important global healthcare issue; it is the leading cause of global mortality, with an increasing incidence identified in both developed and developing countries. It is also an extremely costly disease for healthcare systems unless managed effectively. In this review we aimed to: – Assess the effect of computer-assisted versus oral-and-written history taking on the quality of collected information for the prevention and management of CVD. – Assess the effect of computer-assisted versus oral-and-written history taking on the prevention and management of CVD. Methods: Randomised controlled trials that included participants of 16 years or older at the beginning of the study, who were at risk of CVD (prevention) or were either previously diagnosed with CVD (management). We searched all major databases. We assessed risk of bias using the Cochrane Collaboration tool. Results: We identified two studies. One comparing the two methods of history-taking for the prevention of cardiovascular disease n = 75. The study shows that generally the patients in the experimental group underwent more laboratory procedures, had more biomarker readings recorded and/or were given (or had reviewed), more dietary changes than the control group. The other study compares the two methods of history-taking for the management of cardiovascular disease (n = 479). The study showed that the computerized decision aid appears to increase the proportion of patients who responded to invitations to discuss CVD prevention with their doctor. The Computer-Assisted History Taking Systems (CAHTS) increased the proportion of patients who discussed CHD risk reduction with their doctor from 24% to 40% and increased the proportion who had a specific plan to reduce their risk from 24% to 37%. Discussion: With only one study meeting the inclusion criteria, for prevention of CVD and one study for management of CVD we did not gather sufficient evidence to address all of the objectives of the review. We were unable to report on most of the secondary patient outcomes in our protocol. Conclusions: We tentatively conclude that CAHTS can provide individually-tailored information about CVD prevention. However, further primary studies are needed to confirm these findings. We cannot draw any conclusions in relation to any other clinical outcomes at this stage. There is a need to develop an evidence base to support the effective development and use of CAHTS in this area of practice. In the absence of evidence on effectiveness, the implementation of computer-assisted history taking may only rely on the clinicians’ tacit knowledge, published monographs and viewpoint articles

Electronic Health Record Functionality Needed to Better Support Primary Care

Electronic health records (EHRs) must support primary care clinicians and patients, yet many clinicians remain dissatisfied with their system. This manuscript presents a consensus statement about gaps in current EHR functionality and needed enhancements to support primary care. The Institute of Medicine primary care attributes were used to define needs and Meaningful Use (MU) objectives to define EHR functionality. Current objectives remain disease- rather than whole-person focused, ignoring factors like personal risks, behaviors, family structure, and occupational and environmental influences. Primary care needs EHRs to move beyond documentation to interpreting and tracking information over time as well as patient partnering activities, support for team based care, population management tools that deliver care, and reduced documentation burden. While Stage 3 MU’s focus on outcomes is laudable, enhanced functionality is still needed including EHR modifications, expanded use of patient portals, seamless integration with external applications, and advancement of national infrastructure and policies

Ensuring sample quality for biomarker discovery studies - Use of ict tools to trace biosample life-cycle

The growing demand of personalized medicine marked the transition from an empirical medicine to a molecular one, aimed at predicting safer and more effective medical treatment for every patient, while minimizing adverse effects. This passage has emphasized the importance of biomarker discovery studies, and has led sample availability to assume a crucial role in biomedical research. Accordingly, a great interest in Biological Bank science has grown concomitantly. In biobanks, biological material and its accompanying data are collected, handled and stored in accordance with standard operating procedures (SOPs) and existing legislation. Sample quality is ensured by adherence to SOPs and sample whole life-cycle can be recorded by innovative tracking systems employing information technology (IT) tools for monitoring storage conditions and characterization of vast amount of data. All the above will ensure proper sample exchangeability among research facilities and will represent the starting point of all future personalized medicine-based clinical trials

Effective dissemination: An examination of the costs of implementation strategies for the AOD field.

This document is Part Two of a 3-part series by the National Centre for Education and Training on Addiction (NCETA) examining the effectiveness, costs and theories related to dissemination and implementation of research into practice. Part One is a systematic literature review that evaluated the effectiveness of 16 different dissemination strategies for facilitating the implementation of new research, programs and treatments to improve outcomes for clients with alcohol and other drug-related problems. Part Two involves an examination of the costs associated with using such strategies, and Part Three is an examination of the theories and models of change underlying the use of strategies. In this Part, the costs of implementing innovations and the implications of using dissemination strategies for the alcohol and other drug (AOD) field are examined. Part One in this series is a systematic review of the effectiveness of dissemination and implementation strategies (Bywood, Lunnay, & Roche, 2008). However, evidence related to economic considerations was not based on a systematic search using relevant terms associated with economic analysis. Rather, it is a summary of the evidence from the systematic review on effectiveness that also contained data on costs of using an implementation strategy. All studies in Part One that showed evidence that a particular strategy was effective in changing practitioners’ behaviour or improving organisational efficiency were scrutinised to determine whether an economic analysis had also been undertaken. These studies then formed the evidence base for the present report. An implementation strategy can be effective, without being cost-effective. Thus, from an economic perspective, the key question is whether certain dissemination and implementation activities involve a more efficient use of limited resources compared to other activities. The key research questions for this study were: 1. What are the economic considerations for the use of effective dissemination and implementation strategies? 2. Which implementation strategies provide an efficient and cost-effective means by which to facilitate uptake of innovations by the AOD field? The key findings from this review are: • CME was generally effective and cost-effective, although formats differed substantially • Educational outreach showed mixed results on cost-effectiveness • Educational materials were relatively cheap, but had little effectiveness • Multi-faceted approaches differed substantially in context and content, making it difficult to make meaningful comparisons on the basis of cost • The evidence base of studies containing good quality economic analyses was limited (only 9 of the 16 strategies were evaluated for costs) • Studies that reported on costs of implementation strategies were heterogeneous, reporting of details and quality of methodology was poor, and data collection was incomplete • Few studies evaluated costs of implementation strategies in the AOD field • There is a need for future evaluation studies to examine efficiency through use of economic evaluation