Successful Implementation of Clinical Information Technology: Seven Key Lessons from CPOE.

OBJECTIVES: To identify and describe the most critical strategic and operational contributors to the successful implementation of clinical information technologies, as deployed within a moderate sized system of U.S. community hospitals. BACKGROUND AND SETTING: CHRISTUS Health is a multi-state system comprised of more than 350 services and 60 hospitals with over 9 000 physicians. The Santa Rosa region of CHRISTUS Health, located in greater San Antonio, Texas is comprised of three adult community hospital facilities and one Children's hospital each with bed capacities of 142-180. Computerized Patient Order Entry (CPOE) was first implemented in 2012 within a complex market environment. The Santa Rosa region has 2 417 credentialed physicians and 263 mid-level allied health professionals. METHODS: This report focuses on the seven most valuable strategies deployed by the Health Informatics team in a large four hospital CHRISTUS region to achieve strong CPOE adoption and critical success lessons learned. The findings are placed within the context of the literature describing best practices in health information technology implementation. RESULTS: While the elements described involved discrete de novo process generation to support implementation and operations, collectively they represent the creation of a new customer-centric service culture in our Health Informatics team, which has served as a foundation for ensuring strong clinical information technology adoption beyond CPOE. CONCLUSION: The seven success factors described are not limited in their value to and impact on CPOE adoption, but generalize to - and can advance success in - varied other clinical information technology implementations across diverse hospitals. A number of these factors are supported by reports in the literature of other institutions' successful implementations of CPOE and other clinical information technologies, and while not prescriptive to other settings, may be adapted to yield value elsewhere.

Place learning in virtual space. III: Investigation of spatial navigation training procedures and their application to fMRI and clinical neuropsychology.

This paper describes the utilization of a desktop virtual environment task, the Computer-Generated (C-G) Arena, in the study of human spatial navigation. First, four experiments examined the efficacy of various training procedures in the C-G Arena. In Experiment 1, participants efficiently located a hidden target after only observing the virtual environment from a fixed position (placement learning). In Experiment 2, participants efficiently located a hidden target after only observing an experimenter search the virtual environment (observational learning). In Experiment 3, participants failed to display a latent learning effect in the virtual environment. In Experiment 4, all training procedures effectively taught participants the layout of the virtual environment, but the observational learning procedure most effectively taught participants the location of a hidden target within the environment. Finally, two experiments demonstrated the application of C-G Arena procedures to neuroimaging (Experiment 5) and neuropsychological (Experiment 6) investigations of human spatial navigation.

The first panic attack: a neurobiological theory.

We extend a neurodevelopmental model of specific phobias to the etiology of an initial panic attack and its elaboration into panic disorder. An important difference between the initial panic attack and specific phobia is the developmental timing of critical emotional experience: Those occurring early in development lead to panic; those occurring later in development lead to specific phobia. By this account, sensory and emotional experiences that occur early in development are stored in a set of modules, each with a unique developmental trajectory. Reinstatement, which occurs during hormonal stress, produces an aggregate of sensory and emotional memories and the first experience of an unexplained panic attack. Panic disorder, which evolves from unexplained panic attacks, involves retrieval of a disaggregate set of sensory and emotional memory fragments supplemented by an inferential fitting of an explanatory context to this incomplete aggregate.

Attention fixation training: training people to form cognitive maps help to control symptoms of panic disorder with agoraphobia.

Nine individuals diagnosed with panic with agoraphobia received three elements of Attentional Fixation Training (AFT): Directed attention to the external environment, directed topographical synthesis, and directed orientation in space-time to control characteristics of panic. They then walked a standard 2.5 km route and practiced these elements upon entering one of the five panic-inducing situations: (a) walking alone near a busy street with the examiner following at 20 m, (b) walking alone near a busy street with the examiner out of client's visual field, (c) shopping with the examiner present, (d) traveling on a bus alone, and (e) shopping alone. Heart rate was monitored in each of these five situations. Except for the case of using public transport, heart rate activity decreased to a considerable extent during AFT practice suggesting AFT elements provided a good way to control symptoms of panic in vivo. Results were discussed within the confines of a model suggesting that an attentional deficit, which produces a spatial disorientation disorder that maintains both panic and agoraphobia, can efficiently be overcome by means of all three AFT tools.

Age-related changes in a human cognitive mapping system: data from a computer-generated environment.

Two studies investigated age-related changes in human spatial cognition. In Study 1, younger and older adults searched computer-generated space, over several trials, for the location of a hidden target. Younger adults, but not older adults, quickly located the target and consistently returned to it. All the younger adults, but few of the older adults, reported using spatial relations among distal cues to navigate the space. In Study 2, young, middle-aged, and older adults performed the same task, but were provided with increased environmental support and pre-task training. The data pattern from Study 1 was replicated, with the performance of middle-aged adults falling between that of young and older adults. Although older adults in Study 2 reported less experience at completing computer-based tasks than did young and middle-aged adults, effects of this differential level of computer experience appeared to diminish over the course of experimental procedures (i.e., group differences that appeared on pre-task non-spatial practice trials were not apparent on a similar post-task trial). Age-related differences in spatial cognition persisted, however. Thus, the current data (a) suggest that a human cognitive mapping system changes over the lifespan, (b) suggest that computer-generated tasks can be sensitive to those changes, and (c) are consistent with a substantial literature investigating age-related changes in human and rodent spatial cognition.

Subtle presentations of post-traumatic stress disorder. Diagnostic issues.

The authors present a set of diagnostic procedures designed to detect subtle presentations of post-traumatic stress disorder (PTSD). Defined as a Type II diagnostic error (a false negative), the authors examine several sources of subtle presentations of PTSD. These include imperfect diagnostic instruments, high base rates, imperfect memory of critical events, imperfect reporting of signs and symptoms, imperfect interpretation of presented signs and symptoms, and diagnostic decisions based on informal clinical judgment. The authors believe that a multistage diagnostic procedure, using instruments with known psychometric properties while simultaneously looking for converging evidence is the best safeguard against missing an appropriate diagnosis of post-traumatic stress disorder.

Who teaches health education in Texas secondary schools?

Although school health education now is seen as a national priority, little descriptive data on teachers responsible for delivering school health education have been collected. This survey provided baseline data on secondary health educators in Texas that, in turn, can be used to compare with data from other states. Questionnaires were received from 205 randomly selected secondary health educators in Texas. Subjects were sorted into two groups, full-time health educators or part-time health educators, based on the number of hours/classes spent teaching health education. Less than 50% of respondents held a degree in health education, 30% did not have a teaching certification in health education, and 10% had no academic background in health education. Those with no background in health education showed significantly less confidence and competence in their teaching ability than those with some background in health education. Almost all felt health education was as important as other courses, but slightly more than one-half felt their administration shared that view. Less than 36% felt other faculty members viewed health education as important as other courses.

A model of Pavlovian conditioning: variations in representations of the unconditional stimulus.

We present a model of Pavlovian excitatory conditioning in which associative strength and malleable central representations of unconditional stimuli determine the strength of conditional responding. Presentation of a conditioned stimulus acts through an experientially determined associative bond to activate a representation of the unconditional stimulus. The activation of the representation produces a conditioned response. A striking feature of the model is its ability to describe changes in conditioned response magnitude in terms of alterations of representations of the unconditional stimulus. Another is its acknowledgement of the capacity of associative bonds to survive behavioral extinction. The model describes much of the data reported from excitatory conditioning experiments and predicts counterintuitive phenomena.

Extinction of a conditioned emotional response: massed and distributed exposures.

Using the lick-suppression methodology of Jacobs, Buttrick & Kennedy (Pavlovian Journal of Biological Science, 23, 29-34, 1988), a conditioned emotional response (CER) was established in 24 rats using off-the-baseline pairings of a light (the conditional stimulus) and brief footshock (the unconditioned stimulus). Following conditioning, the rats were assigned to one of three extinction groups differing in whether they received massed or distributed off-the-baseline exposure to the conditional stimulus. The effects of differential treatment were assessed on-the-baseline on test days, when the extinction of the CER was monitored. Rats receiving a single, long exposure to the conditional stimulus showed greater resistance to extinction than the rats in the distributed groups. They also showed a difference pattern of CER extinction. The results were discussed and compared to similar studies that have explored the massed vs distributed dimension, both in CER and avoidance-extinction (using response prevention or flooding). The relation of animal studies to parallel human studies using exposure therapy was also discussed.

A rapid and sensitive method for measuring the conditional emotional response. II: On-the-baseline excitatory conditioning and extinction.

The present study outlines a rapid and sensitive on-the-baseline conditional emotional response (CER) procedure. Using rats as the experimental subject, the method detects delay conditioning, incubation, extinction and spontaneous recovery. In addition, the method detects conditional responding using electric shock ranging from 0.23 to 0.50 mA as the unconditional stimulus. Because of its speed and sensitivity, the method shelters the subject from unnecessary long-term deprivation and pain.

Incubation of conditional suppression is an associatively-based phenomenon.

Ten rats were deprived of water and trained to lick a tube for saccharin reinforcement. In each of the two sessions that followed, the rats received six contiguous pairings of a 30-second illumination of the houselight and a 0.75 second, 0.10 mA electric shock while licking. No sign of conditioning was observed during the first experimental session, but profound conditioning was observed on the first and subsequent trials of the second conditioning session. No comparable change in the rate of licking was observed in groups of rats that received only presentations of the visual stimulus, only presentations of the electric shock, or random presentation of the visual stimulus and electric shock during the first conditioning session. These data establish that the incubation of conditional suppression is an associative phenomenon.

Evidence of Pavlovian conditioned fear following electrical stimulation of the periaqueductal grey in the rat.

Stimulation of the periaqueductal grey (PAG) has been used to support aversive conditioning in a variety of species with several experimental paradigms. However, it has not been clearly demonstrated whether the behavioral changes produced by PAG stimulation in these paradigms are mediated by associative or nonassociative mechanisms. The present studies demonstrate that electrical stimulation of the PAG in the rat may be used to support associative learning in a Pavlovian paradigm. In each experiment, a fully controlled conditional emotional response (CER) procedure was used to examine the unconditional aversive properties of PAG stimulation. In Experiment 1a, weak associative conditioning was observed when a light CS was paired with PAG stimulation over 6 conditioning trials. In Experiment 1b, robust associative conditioning was obtained with a light CS when 18 conditioning trials were used. In Experiment 2, robust associative conditioning was demonstrated with a tone CS when 6 conditioning trials were used. The results parallel those found when other aversive stimuli are used as a UCS (e.g., footshock or intraorbital air puff), and because the present experiments included the proper control procedures the results clearly indicate that the behavioral changes produced by PAG stimulation are mediated by associative Pavlovian learning mechanisms rather than nonassociative mechanisms such as sensitization or pseudoconditioning. The present technique may be useful for assessing the neuroanatomical and neurochemical substrates underlying the aversive effects of brain-stimulation, and for screening the effects of drugs on the conditional and unconditional responses produced by such stimulation.

Soundtrack contents and depicted sexual violence.

Male undergraduates were exposed to a videotaped depiction of heterosexual rape accompanied by one of three soundtracks: the original soundtrack (featuring dialogue and background rock music), relaxing music, or no sound. Subjective reports of sexual arousal, general enjoyment, perceived erotic content, and perceived pornographic content of the sequence were then provided by each subject. Results indicated that males exposed to the videotape accompanied by the original soundtrack found the sequence significantly more pornographic than males exposed to the sequence accompanied by either relaxing background music or no sound. Ratings of sexual arousal, general enjoyment, and the perceived erotic content, however, did not differ significantly across soundtrack conditions. These results are compatible with the assertion that the content of a video soundtrack may influence the impact of depicted sexual violence.

The effect of post-conditioning exposure to morphine on the retention of a morphine-induced conditioned taste aversion.

In the following experiment, multiple injections of morphine sulfate following the acquisition of a morphine-induced taste aversion had no effect on the retention of the previously acquired aversion. Post-conditioning injections of morphine resulted in the development of physical dependence to morphine and led to a decrement in the ability of morphine to induce a subsequent aversion to a second novel taste. This failure of post-conditioning exposures to morphine to affect a previously acquired morphine-induced taste aversion even though tolerance to morphine had occurred was discussed in the context of Rescorla's event-memory model of conditioning.

Drug exposure and the acquisition and retention of a conditioned taste aversion.

Two experiments examined the effects of preexposure and postexposure to a drug on the acquisition and retention of a conditioned taste aversion induced by that drug. Experiment 1 demonstrated that although drug preexposure attenuated a subsequent conditioned aversion, repeated taste-drug pairings reversed the initial attenuation effect and resulted in nearly complete avoidance of consumption. Experiment 2, however, demonstrated that drug postexposure did not alter a previously established conditioned aversion, although the postexposure experiences were effective in attenuating a conditioned aversion to a second novel solution. It was suggested that conditioned aversions are mediated by ACTH and that preexposure to a drug results in tolerance to that drug, yielding a smaller ACTH response and thereby a weaker aversion.