Journal of the American Medical Informatics Association Case report

Immediate financial impact of computerized clinical decision support for long-term care residents with renal insufficiency: a case study

2012-04-09T07:38:02-07:00

In a randomized trial of a clinical decision support system for drug prescribing for residents with renal insufficiency in a large long-term care facility, analyses were conducted to estimate the system's immediate, direct financial impact. We determined the costs that would have been incurred if drug orders that triggered the alert system had actually been completed compared to the costs of the final submitted orders and then compared intervention units to control units. The costs incurred by additional laboratory testing that resulted from alerts were also estimated. Drug orders were conservatively assigned a duration of 30 days of use for a chronic drug and 10 days for antibiotics. It was determined that there were modest reductions in drug costs, partially offset by an increase in laboratory-related costs. Overall, there was a reduction in direct costs (US$1391.43, net 7.6% reduction). However, sensitivity analyses based on alternative estimates of duration of drug use suggested a reduction as high as US$7998.33 if orders for non-antibiotic drugs were assumed to be continued for 180 days. The authors conclude that the immediate and direct financial impact of a clinical decision support system for medication ordering for residents with renal insufficiency is modest and that the primary motivation for such efforts must be to improve the quality and safety of medication ordering.

Impact of electronic health record implementation on patient flow metrics in a pediatric emergency department

Kennebeck, S. S., Timm, N., Farrell, M. K., Spooner, S. A. — 2012-04-09T07:38:02-07:00

Implementing electronic health records (EHR) in healthcare settings incurs challenges, none more important than maintaining efficiency and safety during rollout. This report quantifies the impact of offloading low-acuity visits to an alternative care site from the emergency department (ED) during EHR implementation. In addition, the report evaluated the effect of EHR implementation on overall patient length of stay (LOS), time to medical provider, and provider productivity during implementation of the EHR. Overall LOS and time to doctor increased during EHR implementation. On average, admitted patients' LOS was 6–20% longer. For discharged patients, LOS was 12–22% longer. Attempts to reduce patient volumes by diverting patients to another clinic were not effective in minimizing delays in care during this EHR implementation. Delays in ED throughput during EHR implementation are real and significant despite additional providers in the ED, and in this setting resolved by 3 months post-implementation.

Implementation of an innovative, integrated electronic medical record (EMR) and public health information exchange for HIV/AIDS

2012-04-09T07:38:02-07:00

Louisiana is severely affected by HIV/AIDS, ranking fifth in AIDS rates in the USA. The Louisiana Public Health Information Exchange (LaPHIE) is a novel, secure bi-directional public health information exchange, linking statewide public health surveillance data with electronic medical record data. LaPHIE alerts medical providers when individuals with HIV/AIDS who have not received HIV care for >12 months are seen at any ambulatory or inpatient facility in an integrated delivery network. Between 2/1/2009 and 1/31/2011, 488 alerts identified 345 HIV positive patients. Of those identified, 82% had at least one CD4 or HIV viral load test over the study follow-up period. LaPHIE is an innovative use of health information exchange based on surveillance data and real time clinical messaging, facilitating rapid provider notification of those in need of treatment. LaPHIE successfully reduces critical missed opportunities to intervene with individuals not in care, leveraging information historically collected solely for public health purposes, not health care delivery, to improve public health.

Clinical decision support in small community practice settings: a case study

2011-10-18T14:19:35-07:00

Using an eight-dimensional model for studying socio-technical systems, a multidisciplinary team of investigators identified barriers and facilitators to clinical decision support (CDS) implementation in a community setting, the Mid-Valley Independent Physicians Association in the Salem, Oregon area. The team used the Rapid Assessment Process, which included nine formal interviews with CDS stakeholders, and observation of 27 clinicians. The research team, which has studied 21 healthcare sites of various sizes over the past 12 years, believes this site is an excellent example of an organization which is using a commercially available electronic-health-record system with CDS well. The eight-dimensional model proved useful as an organizing structure for the evaluation.

Handling anticipated exceptions in clinical care: investigating clinician use of 'exit strategies' in an electronic health records system

2011-10-18T14:19:35-07:00

Unpredictable yet frequently occurring exception situations pervade clinical care. Handling them properly often requires aberrant actions temporarily departing from normal practice. In this study, the authors investigated several exception-handling procedures provided in an electronic health records system for facilitating clinical documentation, which the authors refer to as ‘data entry exit strategies.’ Through a longitudinal analysis of computer-recorded usage data, the authors found that (1) utilization of the exit strategies was not affected by postimplementation system maturity or patient visit volume, suggesting clinicians' needs to ‘exit’ unwanted situations are persistent; and (2) clinician type and gender are strong predictors of exit-strategy usage. Drilldown analyses further revealed that the exit strategies were judiciously used and enabled actions that would be otherwise difficult or impossible. However, many data entries recorded via them could have been ‘properly’ documented, yet were not, and a considerable proportion containing temporary or incomplete information was never subsequently amended. These findings may have significant implications for the design of safer and more user-friendly point-of-care information systems for healthcare.

Phased implementation of electronic health records through an office of clinical transformation

Banas, C. A., Erskine, A. R., Sun, S., Retchin, S. M. — 2011-08-16T13:07:37-07:00

Evidence suggests that when carefully implemented, health information technologies (HIT) have a positive impact on behavior, as well as operational, process, and clinical outcomes. Recent economic stimulus initiatives have prompted unprecedented federal investment in HIT. Despite strong interest from the healthcare delivery community to achieve ‘meaningful use’ of HIT within a relatively short time frame, few best-practice implementation methodologies have been described. Herein we outline HIT implementation strategies at an academic health center with an office of clinical transformation. Seven percent of the medical center's information technology budget was dedicated to the Office of Clinical Transformation, and successful conversion of 1491 physicians to electronic-based documentation was accomplished. This paper outlines the process re-design, end-user adoption, and practice transformation strategies that resulted in a 99.7% adoption rate within 6 months of the introduction of digital documentation.