Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records

<p>Abstract</p> <p>Background</p> <p>We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria.</p> <p>Methods</p> <p>We developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content.</p> <p>Results</p> <p>All of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified.</p> <p>Conclusion</p> <p>If these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.</p

Capturing human intelligence for modelling cognitive-based clinical decision support agents

The success of intelligent agents in clinical care depends on the degree to which they represent and work with human decision makers. This is particularly important in the domain of clinical risk assessment where such agents either conduct the task of risk evaluation or support human clinicians with the task. This paper provides insights into how to understand and capture the cognitive processes used by clinicians when collecting the most important data about a person’s risks. It attempts to create some theoretical foundations for developing clinically justifiable and reliable decision support systems for initial risk screening. The idea is to direct an assessor to the most informative next question depending on what has already been asked using a mixture of probabilities and heuristics. The method was tested on anonymous mental health data collected by the GRiST risk and safety tool (www.egrist.org)

Computerized ICU Data Management Pitfalls and Promises

journal articleBiomedical Informatic

Trends in design of ransomware viruses

The ransomware nightmare is taking over the internet impacting common users,small businesses and large ones. The interest and investment which are pushed into this market each month, tells us a few things about the evolution of both technical and social engineering and what to expect in the short-coming future from them. In this paper we analyze how ransomware programs developed in the last few years and how they were released in certain market segments throughout the deep web via RaaS, exploits or SPAM, while learning from their own mistakes to bring profit to the next level. We will also try to highlight some mistakes that were made, which allowed recovering the encrypted data, along with the ransomware authors preference for specific encryption types, how they got to distribute, the silent agreement between ransomwares, coin-miners and bot-nets and some edge cases of encryption, which may prove to be exploitable in the short-coming future

Conceptual Challenges for Advancing the Socio-Technical Underpinnings of Health Informatics

This discussion paper considers the adoption of socio-technical perspectives and their theoretical and practical influence within the discipline of health informatics. The paper highlights the paucity of discussion of the philosophy, theory and concepts of socio-technical perspectives within health informatics. Instead of a solid theoretical base from which to describe, study and understand human-information technology interactions we continue to have fragmented, unelaborated understandings. This has resulted in a continuing focus on technical system performance and increasingly managerial outputs to the detriment of social and technical systems analysis. It has also limited critical analyses and the adaptation of socio-technical approaches beyond the immediate environment to the broader social systems of contemporary society, an expansion which is increasingly mandated in today’s complex health environment

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

Standards for Scalable Clinical Decision Support: Need, Current and Emerging Standards, Gaps, and Proposal for Progress

Despite their potential to significantly improve health care, advanced clinical decision support (CDS) capabilities are not widely available in the clinical setting. An important reason for this limited availability of CDS capabilities is the application-specific and institution-specific nature of most current CDS implementations. Thus, a critical need for enabling CDS capabilities on a much larger scale is the development and adoption of standards that enable current and emerging CDS resources to be more effectively leveraged across multiple applications and care settings. Standards required for such effective scaling of CDS include (i) standard terminologies and information models to represent and communicate about health care data; (ii) standard approaches to representing clinical knowledge in both human-readable and machine-executable formats; and (iii) standard approaches for leveraging these knowledge resources to provide CDS capabilities across various applications and care settings. A number of standards do exist or are under development to meet these needs. However, many gaps and challenges remain, including the excessive complexity of many standards; the limited availability of easily accessible knowledge resources implemented using standard approaches; and the lack of tooling and other practical resources to enable the efficient adoption of existing standards. Thus, the future development and widespread adoption of current CDS standards will depend critically on the availability of tooling, knowledge bases, and other resources that make the adoption of CDS standards not only the right approach to take, but the cost-effective path to follow given the alternative of using a traditional, ad hoc approach to implementing CDS

Understanding the management of electronic test result notifications in the outpatient setting

<p>Abstract</p> <p>Background</p> <p>Notifying clinicians about abnormal test results through electronic health record (EHR) -based "alert" notifications may not always lead to timely follow-up of patients. We sought to understand barriers, facilitators, and potential interventions for safe and effective management of abnormal test result delivery via electronic alerts.</p> <p>Methods</p> <p>We conducted a qualitative study consisting of six 6-8 member focus groups (N = 44) at two large, geographically dispersed Veterans Affairs facilities. Participants included full-time primary care providers, and personnel representing diagnostic services (radiology, laboratory) and information technology. We asked participants to discuss barriers, facilitators, and suggestions for improving timely management and follow-up of abnormal test result notifications and encouraged them to consider technological issues, as well as broader, human-factor-related aspects of EHR use such as organizational, personnel, and workflow.</p> <p>Results</p> <p>Providers reported receiving a large number of alerts containing information unrelated to abnormal test results, many of which were believed to be unnecessary. Some providers also reported lacking proficiency in use of certain EHR features that would enable them to manage alerts more efficiently. Suggestions for improvement included improving display and tracking processes for critical alerts in the EHR, redesigning clinical workflow, and streamlining policies and procedures related to test result notification.</p> <p>Conclusion</p> <p>Providers perceive several challenges for fail-safe electronic communication and tracking of abnormal test results. A multi-dimensional approach that addresses technology as well as the many non-technological factors we elicited is essential to design interventions to reduce missed test results in EHRs.</p

Patient Access to U.S. Physicians Who Conduct Internet or E-mail Consults

BACKGROUND: E-mail communication has the potential to improve communication between patients and doctors. OBJECTIVE: The objective of the study is to describe the access of patients to physicians who conduct e-mail consults. METHODS: We analyzed data from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative cross-sectional survey of office-based physician visits, in 2001, 2002, and 2003. The main outcome measure was the percentage of visits to a provider who reported doing internet or e-mail consults. RESULTS: There was fewer than 1 in 10 outpatient visits in 2001 (9.2%) to physicians who reported doing internet or e-mail consults, and this did not increase in 2002 (5.8%) or 2003 (5.5%). Access to these physicians was greater among patients who were male, nonminority, lived in the Western United States, seen for pre-/postoperative care, seen by a primary care provider, and not seen by a nurse during their visit. Access to physicians who conducted internet or e-mail consults was independent of other patient (e.g., chronic conditions), provider (e.g., office setting), and visit (e.g., medications prescribed) characteristics. CONCLUSIONS: Access to physicians who do internet or e-mail consults is generally low and did not increase between 2001 and 2003, despite growth in internet access and in other internet-related activities