Reduction in Clinical Variance Using Targeted Design Changes in Computerized Provider Order Entry (CPOE) Order Sets: Impact on Hospitalized Children with Acute Asthma Exacerbation.

OBJECTIVES: Unwarranted variance in healthcare has been associated with prolonged length of stay, diminished health and increased cost. Practice variance in the management of asthma can be significant and few investigators have evaluated strategies to reduce this variance. We hypothesized that selective redesign of order sets using different ways to frame the order and physician decision-making in a computerized provider order entry system could increase adherence to evidence-based care and reduce population-specific variance. PATIENTS AND METHODS: The study focused on the use of an evidence-based asthma exacerbation order set in the electronic health record (EHR) before and after order set redesign. In the Baseline period, the EHR was queried for frequency of use of an asthma exacerbation order set and its individual orders. Important individual orders with suboptimal use were targeted for redesign. Data from a Post-Intervention period were then analyzed. RESULTS: In the Baseline period there were 245 patient visits in which the acute asthma exacerbation order set was selected. The utilization frequency of most orders in the order set during this period exceeded 90%. Three care items were targeted for intervention due to suboptimal utilization: admission weight, activity center use and peak flow measurements. In the Post-Intervention period there were 213 patient visits. Order set redesign using different default order content resulted in significant improvement in the utilization of orders for all 3 items: admission weight (79.2% to 94.8% utilization, p<0.001), activity center (84.1% to 95.3% utilization, p<0.001) and peak flow (18.8% to 55.9% utilization, p<0.001). Utilization of peak flow orders for children ≥8 years of age increased from 42.7% to 94.1% (p<0.001). CONCLUSIONS: Details of order set design greatly influence clinician prescribing behavior. Queries of the EHR reveal variance associated with ordering frequencies. Targeting and changing order set design elements in a CPOE system results in improved selection of evidence-based care.

Determinants of patient satisfaction and willingness to return with emergency care.

STUDY OBJECTIVE: To identify emergency department process of care measures that are significantly associated with satisfaction and willingness to return. METHODS: Patient satisfaction and willingness to return at 5 urban, teaching hospital EDs were assessed. Baseline questionnaire, chart review, and 10-day follow-up telephone interviews were performed, and 38 process of care measures and 30 patient characteristic were collected for each respondent. Overall satisfaction was modeled with ordinal logistic regression. Willingness to return was modeled with logistic regression. RESULTS: During a 1-month study period, 2,899 (84% of eligible) on-site questionnaires were completed. Telephone interviews were completed by 2,333 patients (80% of patients who completed a questionnaire). Patient-reported problems that were highly correlated with satisfaction included help not received when needed (odds ratio [OR] 0.345; 95% confidence interval [CI] 0.261 to 0.456), poor explanation of causes of problem (OR 0.434; 95% CI 0.345 to 0.546), not told about potential wait time (OR 0.479; 95% CI 0.399 to 0.577), not told when to resume normal activities (OR 0.691; 95% CI 0.531 to 0.901), poor explanation of test results (OR 0.647; 95% CI 0.495 to 0.845), and not told when to return to the ED (OR 0.656; 95% CI 0. 494 to 0.871). Other process of care measures correlated with satisfaction include nonacute triage status (OR 0.701, 95% CI 0.578 to 0.851) and number of treatments in the ED (OR 1.164 per treatment; 95% CI 1.073 to 1.263). Patient characteristics that significantly predicted less satisfaction included younger age and black race. Determinants of willingness to return include poor explanation of causes of problem (OR 0.328; 95% CI 0.217 to 0.495), unable to leave a message for family (OR 0.391; 95% CI 0.226 to 0. 677), not told about potential wait time (OR 0.561; 95% CI 0.381 to 0.825), poor explanation of test results (OR 0.541; 95% CI 0.347 to 0.846), and help not received when needed (OR 0.537; 95% CI 0.340 to 0.846). Patients with a chief complaint of hand laceration were less willing to return compared with a reference population of patients with abdominal pain. Willingness to return is strongly predicted by overall satisfaction (OR 2.601; 95% CI 2.292 to 2.951). CONCLUSION: These data identify specific process of care measures that are determinants of patient satisfaction and willingness to return. Efforts to increase patient satisfaction and willingness to return should focus on improving ED performance on these identified process measures.

Benchmarking and quality improvement: the Harvard Emergency Department Quality Study.

PURPOSE: To determine whether feedback of comparative information was associated with improvement in medical record and patient-based measures of quality in emergency departments. SUBJECTS AND METHODS: During 1-month study periods in 1993 and 1995, all medical records for patients who presented to five Harvard teaching hospital emergency departments with one of six selected chief complaints (abdominal pain, shortness of breath, chest pain, hand laceration, head trauma, or vaginal bleeding) were reviewed for the percent compliance with process-of-care guidelines. Patient-reported problems and patient ratings of satisfaction with emergency department care were collected from eligible patients using patient questionnaires. After reviewing benchmark information, emergency department directors designed quality improvement interventions to improve compliance with the process-of-care guidelines and improve patient-reported quality measures. RESULTS: In the preintervention period, 4,876 medical records were reviewed (99% of those eligible), 2,327 patients completed on-site questionnaires (84% of those eligible), and 1,386 patients completed 10-day follow-up questionnaires (80% of a random sample of eligible participants). In the postintervention period, 6,005 medical records were reviewed (99% of those eligible), 2,899 patients completed on-site questionnaires (84% of those eligible), and 2,326 patients completed 10-day follow-up questionnaires (80% of all baseline participants). In multivariate analyses, adjusting for age, urgency, chief complaint, and site, compliance with process-of-care guidelines increased from 55.9% (preintervention) to 60.4% (postintervention, P = 0.0001). We also found a 4% decrease (from 24% to 20%) in the rate of patient-reported problems with emergency department care (P = 0.0001). There were no significant improvements in patient ratings of satisfaction. CONCLUSION: Feedback of benchmark information and subsequent quality improvement efforts led to small, although significant, improvement in compliance with process-of-care guidelines and patient-reported measures of quality. The measures that relied on patient reports of problems with care, rather than patient ratings of satisfaction with care, seemed to be more responsive to change. These results support the value of benchmarking and collaboration.

The effect of supervision of residents on quality of care in five university-affiliated emergency departments.

PURPOSE: To assess the impact of direct supervision of resident physicians by attending physicians on quality of care in emergency departments. METHOD: In 1993, compliance with process-of-care guidelines was measured for 3,667 patients cared for by residents in five emergency departments in Boston and Cambridge, Massachusetts. Those patients presented with abdominal pain, asthma/COPD, chest pain, hand laceration, head trauma, or vaginal bleeding. A follow-up survey to assess patient satisfaction and reported problems with care was completed by 1,094 randomly sampled patients. RESULTS: In multivariate analysis, residents directly supervised by attending physicians had significantly (p < .0001) higher adjusted mean percentage compliance with guidelines (64%) than did residents alone (55%). Better compliance was also associated with higher level of training of the resident and greater patient urgency. There was no significant difference between supervised and unsupervised residents in either adjusted patient satisfaction or reported problems with care. CONCLUSIONS: Direct supervision of residents in emergency departments is significantly associated with better compliance with guidelines, regardless of level of training. However, direct supervision was not shown to influence patients' experience with care.

Patient-specific predictors of ambulance use.

STUDY OBJECTIVE: To determine patient-specific socioeconomic and health status characteristics for patients arriving by ambulance at an emergency department. METHODS: Ambulance use among adult ED patients presenting with abdominal pain, chest pain, head trauma, or shortness of breath was studied at five urban teaching hospitals in the north-eastern United States. Cross-sectional analysis within a prospective cohort study of 4,979 consecutive patients was performed using an interval sequence subset of 2,315 patients (84% of those eligible) to whom questionnaires were administered. Ambulance use (21% of surveyed patients; 26% of all patients) was analyzed with logistic regression. RESULTS: Predictors of ambulance use included age greater than 65 years (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.34 to 2.82); clinical severity (OR, 3.11; 95% CI, 2.27 to 4.25); poverty (OR, 1.40; 95% CI, 1.08 to 1.83); physical function (OR, 1.05; 95% CI, 1.02 to 1.09 for each point of worsening function on a 12-point physical function scale); and various types of health insurance coverage. Race, sex, education, Medicaid coverage, frequency of ED use, living arrangements, and primary physician availability were not predictive in multivariate analysis of surveyed patients. CONCLUSION: Ambulance use varies by age, clinical severity, income, patient-specific characteristics of physical function, and type of health insurance. Medicaid coverage and frequent ED use are not predictive of increased ambulance use.

Designing an emergency medicine physician workstation to support risk management in decision making.

The practice of emergency medicine requires rapid decision making. The speed of decision making in the face of limited information contributes to the high risk of medical malpractice suits. We explore design approaches to an emergency physician electronic medical record product, EMstation, that may reduce the risk of adverse medical events by providing cues and tools while the patient may still be in the emergency department. EMstation is an Emergency Medicine Physician Workstation base on a Microsoft Windows 3.1 user interface. Because adaptation and adaptability to physician needs are critical to user acceptance, design to workflow, multisite end user customization, and integrated database support are used to support risk management documentation in EMstation. This article describes techniques that can be incorporated into electronic medical products which may prevent adverse medical events.

Temporal representation of clinical algorithms using expert-system and database tools.

The HyperLipid Advisory System combines a rule-based implementation of a clinical algorithm (the NIH Cholesterol Education Program Expert Panel recommendations) with a temporal representation that facilitates reasoning over time while maintaining efficient storage in a standard database. The temporal representation consists of objects that model point events such as visits and interval events such as specific therapies. These objects are combined into abstractions called phases, which correspond to higher level clinical concepts such as a diet or drug treatment. The time-oriented data objects are referenced in the rules using a custom-tailored operator query language. Between user sessions relevant clinical data are stored in external files. When the advisory system is reconsulted, this information is retrieved and mapped back into an object-oriented format. Use of a commercially available expert-system shell for such tasks allows algorithm implementation in standard personal computing environments.