Clinical event management using push technology--implementation and evaluation at two health care centers.

For two years, beginning in 1995, we developed and implemented a novel method for delivering patient information directly to clinicians. Using rules based logic to scan data bound for an electronic medical record, messages were automatically written that alert care providers to important patient information. These messages were transmitted electronically to either existing email accounts or to wide-screen pagers, or to both. This system now is operational at two medical centers. We describe the model and methods that led to its successful implementation and compare it to other ways of delivering patient information.

Toward an evaluation of an integrated clinical imaging system: identifying clinical benefits.

Integrated clinical imaging systems can provide the foundation for future computer-based patient record systems as recommended by the Institute of Medicine. However, documenting the benefits of such systems is difficult. This paper reports an evaluation of a clinical imaging system that is integrated with an on-line electronic patient record. The evaluation used interviews and observations to identify what physicians thought were the benefits of this system. Reported benefits may be classified into patient care benefits, educational benefits, and productivity and cost-reduction benefits Physicians said that the imaging system provided patient care benefits by: improving clinical communication and decision making, making care more patient-based, reducing the number of procedures and patient risks, and improving record keeping. Educational benefits they reported included: improving communication, providing broad "real" experience, and improving supervision. These benefits may be reflected in increased productivity and cost reduction by increasing time savings, reducing clerical work, improving morale, and reducing the costs of care. The approach described in this study was valuable in identifying potential benefits of a clinical information system. The findings point the way to realization of benefits for other systems, and, ultimately, for computer-based patient records.

Evaluation of user acceptance of a clinical expert system.

OBJECTIVE: To measure the attitudes of physicians and nurses who use the Health Evaluation through Logical Processing (HELP) clinical information system. DESIGN: Questionnaire survey of 360 attending physicians and 960 staff nurses practicing at the LDS Hospital. The physicians' responses were signed, permitting follow-up for nonresponse and use of demographic data from staff files. The nurses' responses were anonymous and their demographic data were obtained from the questionnaires. MEASUREMENTS: Fixed-choice questions with a Likert-type scale, supplemented by free-text comments. Question categories included: computer experience; general attitudes about impact of the system on practice; ranking of available functions; and desired future capabilities. RESULTS: The response rate was 68% for the physicians and 39% for the nurses. Age, specialty, and general computer experience did not correlate with attitudes. Access to patient data and clinical alerts were rated highly. Respondents did not feel that expert computer systems would lead to external monitoring, or that these systems might compromise patient privacy. The physicians and nurses did not feel that computerized decision support decreased their decision-making power. CONCLUSION: The responses to the questionnaire and "free-text comments" provided encouragement for future development and deployment of medical expert systems at LDS Hospital and sister hospitals. Although there has been some fear on the part of medical expert system developers that physicians would not adapt to or appreciate recommendations given by these systems, the results presented here are promising and may be of help to other system developers and evaluators.

Improving empiric antibiotic selection using computer decision support.

BACKGROUND: Physicians frequently need to start antibiotic therapy before the results of bacterial cultures and antibiotic susceptibility tests are available. We developed and evaluated a computerized antibiotic consultant to assist physicians in the selection of appropriate empiric antibiotics. METHODS: We used a two-stage random-selection study to compare antibiotics suggested by the antibiotic consultant with 482 associated antibiotic susceptibility results and the concurrent antibiotics ordered by physicians. The antibiotics ordered by randomized physicians were then compared between crossover periods of antibiotic consultant use. RESULTS: The antibiotic consultant suggested an antibiotic regimen to which all isolated pathogens were shown to be susceptible for 453 (94%) of 482 culture results, while physicians ordered an antibiotic regimen to which all isolated pathogens were susceptible for 369 culture results (77%) (P < .001). The physicians who prescribed antibiotics to which all pathogens were susceptible did so a mean of 21 hours after the culture specimens were collected. Physicians ordered appropriate antibiotics within 12 hours of the culture collection significantly more often when they had use of the antibiotic consultant than during the period before use (P < .035). Moreover, 88% of the physicians stated they would recommend the program to other physicians, 85% said the program improved their antibiotic selection, and 81% said they felt use of the program improved patient care. CONCLUSIONS: Information from computer-based medical records can be used to help improve physicians' selection of empiric antibiotics for infections.

Evaluation of a Computerized Clinical Information System (Micromedex).

This paper summarizes data collected as part of a project designed to identify and assess the technical and organizational problems associated with the implementation and evaluation of a Computerized Clinical Information System (CCIS), Micromedex, in three U.S. Department of Veterans Affairs Medical Centers (VAMCs). The study began in 1987 as a national effort to implement decision support technologies in the Veterans Administration Decentralized Hospital Computer Program (DHCP). The specific objectives of this project were to (1) examine one particular decision support technology, (2) identify the technical and organizational barriers to the implementation of a CCIS in the VA host environment, (3) assess the possible benefits of this system to VA clinicians in terms of therapeutic decision making, and (4) develop new methods for identifying the clinical utility of a computer program designed to provide clinicians with a new information tool. The project was conducted intermittently over a three-year period at three VA medical centers chosen as implementation and evaluation test sites for Micromedex. Findings from the Kansas City Medical Center in Missouri are presented to illustrate some of the technical problems associated with the implementation of a commercial database program in the DHCP host environment, the organizational factors influencing clinical use of the system, and the methods used to evaluate its use. Data from 4581 provider encounters with the CCIS are summarized. Usage statistics are presented to illustrate the methodological possibilities for assessing the "benefits and burdens" of a computerized information system by using an automated collection of user demographics and program audit trails that allow evaluators to monitor user interactions with different segments of the database.

Evaluating medical expert systems.

Approximately 90% of all computerized medical expert systems have not been evaluated in clinical environments. This paper: identifies the principal methods used to assess the performance of medical expert systems in both laboratory and clinical settings, describes the different research strategies used in the evaluation of medical expert systems at different development stages, and discusses past evaluation efforts in relationship to future applications of different decision support technologies and expert systems in health care.