Evaluation of a Korean version of a tool for assessing the incorporation of human factors into a medication-related decision support system: the I-MeDeSA.

OBJECTIVE: The Instrument for Evaluating Human-Factor Principles in Medication-Related Decision Support Alerts (I-MeDeSA) was developed recently in the US with a view towards improving considerations of human-factor principles when designing alerts for clinical decision support (CDS) systems. This study evaluated the generalizability of this tool, in cooperation with its authors, across cultures by applying it to a Korean system. We also examined opportunities to promote user acceptance of the system. METHODS: We developed a Korean version of the I-MeDeSA (K-I-MeDeSA) and used it to evaluate drug-drug interaction alerts in a large academic tertiary hospital in Seoul. We involved four reviewers (A, B, C, and D). Two (A and B) conducted the initial independent scoring, while the other two (C and D) performed a final review and assessed feedback from the initial reviewers. The obtained scores were compared with those from 13 previously reported CDS systems. The feedback was summarized qualitatively. RESULTS: The translation of the I-MeDeSA had excellent interrater agreement in terms of face validity (scale-level content validity index = 0.95). The system's K-I-MeDeSA score was 10 out of 26, with a good agreement between reviewers (κ = 0.77), which showed a lack of human-factor considerations. The reviewers readily identified two of the nine principles that needed primary improvement: prioritization and text-based information. The reviewers also expressed difficulty judging the following four principles: alarm philosophy, visibility, color, and learnability and confusability. CONCLUSION: The K-I-MeDeSA was semantically and operationally equivalent to the original tool. Only minor cultural problems were identified, leading the reviewers to suggest the need for clarification of certain words plus a more detailed description of the tool's rationale and exemplars. Further evaluation is needed to empirically assess whether the implementation of changes in an electronic health record system could improve the adoption of CDS alerts.

Towards meaningful medication-related clinical decision support: recommendations for an initial implementation.

SUMMARY: Clinical decision support (CDS) can improve safety, quality, and cost-effectiveness of patient care, especially when implemented in computerized provider order entry (CPOE) applications. Medication-related decision support logic forms a large component of the CDS logic in any CPOE system. However, organizations wishing to implement CDS must either purchase the computable clinical content or develop it themselves. Content provided by vendors does not always meet local expectations. Most organizations lack the resources to customize the clinical content and the expertise to implement it effectively. In this paper, we describe the recommendations of a national expert panel on two basic medication-related CDS areas, specifically, drug-drug interaction (DDI) checking and duplicate therapy checking. The goals of this study were to define a starter set of medication-related alerts that healthcare organizations can implement in their clinical information systems. We also draw on the experiences of diverse institutions to highlight the realities of implementing medication decision support. These findings represent the experiences of institutions with a long history in the domain of medication decision support, and the hope is that this guidance may improve the feasibility and efficiency CDS adoption across healthcare settings.

Assessing the difficulty and time cost of de-identification in clinical narratives.

OBJECTIVE: To characterize the difficulty confronting investigators in removing protected health information (PHI) from cross-discipline, free-text clinical notes, an important challenge to clinical informatics research as recalibrated by the introduction of the US Health Insurance Portability and Accountability Act (HIPAA) and similar regulations. METHODS: Randomized selection of clinical narratives from complete admissions written by diverse providers, reviewed using a two-tiered rater system and simple automated regular expression tools. For manual review, two independent reviewers used simple search and replace algorithms and visual scanning to find PHI as defined by HIPAA, followed by an independent second review to detect any missed PHI. Simple automated review was also performed for the "easy" PHI that are number- or date-based. RESULTS: From 262 notes, 2074 PHI, or 7.9 +/- 6.1 per note, were found. The average recall (or sensitivity) was 95.9% while precision was 99.6% for single reviewers. Agreement between individual reviewers was strong (ICC = 0.99), although some asymmetry in errors was seen between reviewers (p = 0.001). The automated technique had better recall (98.5%) but worse precision (88.4%) for its subset of identifiers. Manually de-identifying a note took 87.3 +/- 61 seconds on average. CONCLUSIONS: Manual de-identification of free-text notes is tedious and time-consuming, but even simple PHI is difficult to automatically identify with the exactitude required under HIPAA.

Use of verbal protocol analysis for identification of ADE signals.

We describe the use of verbal protocol analysis for evaluating the textual signals used by pharmacists for detection of adverse drug events (ADEs). "Think aloud" technique was used to gain insight into how pharmacists reason about ADE occurrence, when reading patient progress notes. We used case-scenarios for five ADEs consisting of information regarding patient history, medications, laboratory results, vital signs and patient progress notes. Pharmacists extensively used information present in the progress notes to make inferences about ADEs.

Argininemia.

The clinical features of argininemia in two cousins included hyperactivity, spasticity, ataxia, retardation, and repeated attacks of hyperammonemia. Study of a large kindred suggests that arginase-deficiency is transmitted as a Mendelian recessive. Treatment with an essential amino acid mixture with the total nitrogen intake limited to the requirement, controlled the hyperammonemia, reduced the plasma arginine level, and permitted a marked clinical improvement. There has been a significant increase in intelligence levels; the previously retarded children are now approaching the normal range of function.

The therapy of hyperammonemia due to ornithine transcarbamylase defiency in a male neonate.

Ornithine transcarbamylase deficiency in the male neonate has been considered to be invariably fatal because of the severity of the hyperammonemia. An extreme degree of hyperammonemia in a male neonate was brought under control by a series of exchange transfusions, prolonged peritoneal dialysis, adequate caloric intake, and a mixture of essential amino acids with an excess of aspartic acid and arginine. After the initial phase, it was possible to maintain the plasma ammonia level with dietary therapy alone, in spite of a number of complications that might be expected to cause tissue damage and increase the hyperammonemia.

Cystine deficiency during dietotherapy of homocystinemia.

Cystine deficiency was inadvertently produced in a boy receiving specific dietary therapy for homocystinuria. This was manifested as a loss in weight, the reappearance of significant amounts of homocystine in the plasma and urine, and the elevation of the plasma methionine level. In addition, there was a significant reduction in the level of cystine in the plasma. This reduction in plasma cystine level differentiates cystine deficiency from loss of biochemical control due to failure to keep the prescribed diet. The addition of cystine to the regime of this child, without any other dietary modification, resulted in a complete remission.