Reducing risk with clinical decision support: a study of closed malpractice claims.

OBJECTIVE: Identify clinical opportunities to intervene to prevent a malpractice event and determine the proportion of malpractice claims potentially preventable by clinical decision support (CDS). MATERIALS AND METHODS: Cross-sectional review of closed malpractice claims over seven years from one malpractice insurance company and seven hospitals in the Boston area. For each event, clinical opportunities to intervene to avert the malpractice event and the presence or absence of CDS that might have a role in preventing the event, were assigned by a panel of expert raters. Compensation paid out to resolve a claim (indemnity), was associated with each CDS type. RESULTS: Of the 477 closed malpractice cases, 359 (75.3%) were categorized as substantiated and 195 (54%) had at least one opportunity to intervene. Common opportunities to intervene related to performance of procedure, diagnosis, and fall prevention. We identified at least one CDS type for 63% of substantiated claims. The 41 CDS types identified included clinically significant test result alerting, diagnostic decision support and electronic tracking of instruments. Cases with at least one associated intervention accounted for $40.3 million (58.9%) of indemnity. DISCUSSION: CDS systems and other forms of health information technology (HIT) are expected to improve quality of care, but their potential to mitigate risk had not previously been quantified. Our results suggest that, in addition to their known benefits for quality and safety, CDS systems within HIT have a potential role in decreasing malpractice payments. CONCLUSION: More than half of malpractice events and over $40 million of indemnity were potentially preventable with CDS.

Increasing patient engagement: patients' responses to viewing problem lists online.

OBJECTIVE: To characterize the opinions, emotions, and actions taken by patients who viewed their electronic problem list via an online personal health record (PHR). MATERIALS AND METHODS: An online survey of patients who viewed their problem lists, as maintained by their healthcare provider, in a web-based PHR linked to an electronic health record for the first time. RESULTS: A total 3,649 patients completed the survey, yielding a response rate of 42.1%. Patient attitudes towards the problem list function were positive overall, with 90.4% rating it at least somewhat useful and 86.7% reporting they would probably or definitely use it again. Nearly half (45.6%) of patients identified at least one major or minor problem missing from their list. After viewing the list, 56.1% of patients reported taking at least one action in response, with 32.4% of patients reporting that they researched a condition on the Internet, 18.3% reported that they contacted their healthcare provider and 16.7% reported changing or planning to change a health behavior (patients could report multiple actions). 64.7% of patients reported feeling at least somewhat happy while viewing their problem list, though others reported feeling sad (30.4%), worried (35.7%) or scared (23.8%) (patients could report multiple emotions). A smaller number of patients reported feeling angry (16.6%) or ashamed (14.3%). Patients who experienced an emotional response were more likely to take action. CONCLUSION: Overall, patients found the ability to view their problem lists very useful and took action in response to the information. However, some had negative emotions. More research is needed into optimal strategies for supporting patients receiving this information.

Provider use of and attitudes towards an active clinical alert: a case study in decision support.

BACKGROUND: In a previous study, we reported on a successful clinical decision support (CDS) intervention designed to improve electronic problem list accuracy, but did not study variability of provider response to the intervention or provider attitudes towards it. The alert system accurately predicted missing problem list items based on health data captured in a patient's electronic medical record. OBJECTIVE: To assess provider attitudes towards a rule-based CDS alert system as well as heterogeneity of acceptance rates across providers. METHODS: We conducted a by-provider analysis of alert logs from the previous study. In addition, we assessed provider opinions of the intervention via an email survey of providers who received the alerts (n = 140). RESULTS: Although the alert acceptance rate was 38.1%, individual provider acceptance rates varied widely, with an interquartile range (IQR) of 14.8%-54.4%, and many outliers accepting none or nearly all of the alerts they received. No demographic variables, including degree, gender, age, assigned clinic, medical school or graduation year predicted acceptance rates. Providers' self-reported acceptance rate and perceived alert frequency were only moderately correlated with actual acceptance rates and alert frequency. CONCLUSIONS: Acceptance of this CDS intervention among providers was highly variable but this heterogeneity is not explained by measured demographic factors, suggesting that alert acceptance is a complex and individual phenomenon. Furthermore, providers' self-reports of their use of the CDS alerting system correlated only modestly with logged usage.