Experience in Implementing Inpatient Clinical Note Capture via a Provider Order Entry System

Care providers' adoption of computer-based health-related documentation ("note capture”) tools has been limited, even though such tools have the potential to facilitate information gathering and to promote efficiency of clinical charting. The authors have developed and deployed a computerized note-capture tool that has been made available to end users through a care provider order entry (CPOE) system already in wide use at Vanderbilt. Overall note-capture tool usage between January 1, 1999, and December 31, 2001, increased substantially, both in the number of users and in their frequency of use. This case report is provided as an example of how an existing care provider order entry environment can facilitate clinical end-user adoption of a computer-assisted documentation tool—a concept that may seem counterintuitive to som

FHIRChain: Applying Blockchain to Securely and Scalably Share Clinical Data

Secure and scalable data sharing is essential for collaborative clinical decision making. Conventional clinical data efforts are often siloed, however, which creates barriers to efficient information exchange and impedes effective treatment decision made for patients. This paper provides four contributions to the study of applying blockchain technology to clinical data sharing in the context of technical requirements defined in the "Shared Nationwide Interoperability Roadmap" from the Office of the National Coordinator for Health Information Technology (ONC). First, we analyze the ONC requirements and their implications for blockchain-based systems. Second, we present FHIRChain, which is a blockchain-based architecture designed to meet ONC requirements by encapsulating the HL7 Fast Healthcare Interoperability Resources (FHIR) standard for shared clinical data. Third, we demonstrate a FHIRChain-based decentralized app using digital health identities to authenticate participants in a case study of collaborative decision making for remote cancer care. Fourth, we highlight key lessons learned from our case study

Understanding patient-provider communication entered via a patient portal system

ABSTRACT Our study examines patient-provider communication via a patient portal in a large medical center. Our study is based on 1172 interactions made among stakeholders concerning 100 patients who are randomly selected from the 2009 MyHealthAtVanderbilt.com (a patient portal at the Vanderbilt Medical Center) patient pool; among which, 35 use the patient portal for messages. The findings show a wide range of topics discussed and ways in which patients provide and seek information as well as express psychosocial and emotional needs. In addition, while the patient portal has advantages over traditional communication technologies, it was not the primary communication media for our study sample. More research is needed to better elucidate barriers to the use of patient portals and the optimal methods of communication in differing contexts

Effect of CPOE User Interface Design on User-Initiated Access to Educational and Patient Information during Clinical Care

Objective: Authors evaluated whether displaying context sensitive links to infrequently accessed educational materials and patient information via the user interface of an inpatient computerized care provider order entry (CPOE) system would affect access rates to the materials. Design: The CPOE of Vanderbilt University Hospital (VUH) included "baseline” clinical decision support advice for safety and quality. Authors augmented this with seven new primarily educational decision support features. A prospective, randomized, controlled trial compared clinicians' utilization rates for the new materials via two interfaces. Control subjects could access study-related decision support from a menu in the standard CPOE interface. Intervention subjects received active notification when study-related decision support was available through context sensitive, visibly highlighted, selectable hyperlinks. Measurements: Rates of opportunities to access and utilization of study-related decision support materials from April 1999 through March 2000 on seven VUH Internal Medicine wards. Results: During 4,466 intervention subject-days, there were 240,504 (53.9/subject-day) opportunities for study-related decision support, while during 3,397 control subject-days, there were 178,235 (52.5/subject-day) opportunities for such decision support, respectively (p = 0.11). Individual intervention subjects accessed the decision support features at least once on 3.8% of subject-days logged on (278 responses); controls accessed it at least once on 0.6% of subject-days (18 responses), with a response rate ratio adjusted for decision support frequency of 9.17 (95% confidence interval 4.6-18, p < 0.0005). On average, intervention subjects accessed study-related decision support materials once every 16 days individually and once every 1.26 days in aggregate. Conclusion: Highlighting availability of context-sensitive educational materials and patient information through visible hyperlinks significantly increased utilization rates for study-related decision support when compared to "standard” VUH CPOE methods, although absolute response rates were lo

Identifying and addressing barriers to implementing core electronic health record use metrics for ambulatory care: Virtual consensus conference proceedings

Precise, reliable, valid metrics that are cost-effective and require reasonable implementation time and effort are needed to drive electronic health record (EHR) improvements and decrease EHR burden. Differences exist between research and vendor definitions of metrics. PROCESS:  We convened three stakeholder groups (health system informatics leaders, EHR vendor representatives, and researchers) in a virtual workshop series to achieve consensus on barriers, solutions, and next steps to implementing the core EHR use metrics in ambulatory care. CONCLUSION:  Actionable solutions identified to address core categories of EHR metric implementation challenges include: (1) maintaining broad stakeholder engagement, (2) reaching agreement on standardized measure definitions across vendors, (3) integrating clinician perspectives, and (4) addressing cognitive and EHR burden. Building upon the momentum of this workshop\u27s outputs offers promise for overcoming barriers to implementing EHR use metrics

Original Paper Evaluating Structural Change in a Reference Terminology

Background: Clinical terminologies, like the domains they model, may change over time. Existing methods for identifying and characterizing terminology change, address individual concepts and their interrelationships rather than the overall structure of the terminology. Exposing high level terminology structure may improve developers ’ and users ’ ability to identify changes occurring over time. Objectives: To describe and demonstrate novel structural attributes for terminologies. Methods: We measured novel structural attributes of four successive versions of the National Drug File Reference Terminology Physiologic Effects hierarchy. Attributes included measures for overall size, dimension (ie, width, height, mass, depth), complexity (i.e., node recurrence, leafiness, branchiness) and balance (i.e., skew, variation, smoothness). Results: Among the four versions, the terminology size increased from 711 to 1638 concepts, increased in complexity, but did not improve in terms of symmetry. Conclusions: Visualizing and characterizing the structure of successive terminology versions revealed how the terminology changed at a high level, and where it may have been relatively over specified to meet modeling- or use-based needs