Organizational challenges in developing one of the Nationwide Health Information Network trial implementation awardees.

Health care in the United States is rarely delivered in a coordinated manner. Current methods to share patient information are inefficient and may lead to medical errors, higher readmission rates, and delays in the delivery of needed health services. This qualitative study describes lessons learned concerning the early implementation of one Nationwide Health Information Network (NHIN) site in Long Beach, CA during its first year of operation. The Long Beach Network for Health (LBNH) focused on an incremental effort to exchange health information. Despite a limited concentration on emergency department care, virtually all respondents noted concerns regarding the sustainability, or business case, for the exchange of health information. Nevertheless, respondents were encouraged by progress on technological challenges and user requirements during this first year. The early gains in this process may, in turn, have laid the groundwork for future efforts to expand beyond the emergency department.

Provider stakeholders' perceived benefit from a nascent health information exchange: a qualitative analysis.

We sought to better understand the perceived costs and benefits of joining a nascent health information exchange (HIE) from the perspective of potential provider organization participants. We therefore conducted semi-structured interviews with organizational representatives. Interview transcriptions were thematically coded, and coded text was subsequently aggregated to summarize the breadth and depth of responses. Although no respondents expected HIE to result in net financial benefit to their organization, all respondents recognized some potential benefits, and some respondents expected HIE to result in overall organizational benefit. Disproportionate benefit was expected for the poorest, sickest patients. Many respondents had concerns about HIE increasing the risk of data security breaches, and these concerns were most pronounced at larger organizations. We found little evidence of organizational concern regarding loss of patients to other organizations or publication of unfavorable quality data. If HIE's greatest benefactors are indeed the poorest, sickest patients, our current health care financing environment will make it difficult to align HIE costs with benefits. To sustain HIE, state and federal governments may need to consider ongoing subsidies. Furthermore, these governments will need to ensure that policies regulating data exchange have sufficient nationwide coordination and liability limitations that the perceived organizational risks of joining HIEs do not outweigh perceived benefits. HIE founders can address organizational concerns by attempting to coordinate HIE policies with those of their largest founding organizations, particularly for data security policies. Early HIE development and promotional efforts should not only focus on potential benefits, but should also address organizational concerns.

Voluntary physician adoption of an inpatient electronic medical record by obstetrician-gynecologists.

OBJECTIVE: The purpose of this study was to review the utilization statistics for voluntary physician adoption of a comprehensive inpatient electronic record by community obstetrician-gynecologists. STUDY DESIGN: A retrospective analysis of administrative data on the utilization of a modern electronic medical record system in a private hospital setting was performed. The physician statistics for order entry and physician documentation pre- and postimplementation were compared. RESULTS: During the study period monthly hospital average was 268 discharges per month and 64.9 orders per discharge. Utilizing the prior stand alone order entry system, 38.7% of orders were directly entered by physicians, and, following implementation, this rose to 72.1% with phone/verbal orders reduced by 44.9%. Monthly transcription rates of history and physical, consultations, operative and discharge summary notes were reduced by 61.5%, 75.8%, 56.6%, and 88.2%, respectively, over the study time period. CONCLUSION: A well designed electronic medical record can be utilized in the voluntary private inpatient setting with significant physician adoption.

Optimizing the acceptance of medication-based alerts by physicians during CPOE implementation in a community hospital environment.

There are significant challenges surrounding the implementation of CPOE systems in community hospitals without a mandate for system use. One of these is to incorporate clinical decision support such as medication-based alerts, which are key to benefit realization, but can be perceived adversely by busy physicians trying to learn a new system, without negatively affecting usability and adoption. We describe a phased, iterative approach to incorporating medical-based alerts into a successful CPOE deployment. During the first 8 months after system activation, we continuously monitored the frequency of alert presentation, the frequency of "positive" responses to the alerts and physician satisfaction with each of these. Responses included alterations in filtering strategies, changes in individual drug profiles; changes in user display options; and the addition or withdrawal of entire alert categories in order to decrease maximize value and acceptance. With this strategy we were able to document order removal or modification rates of 21-66% for 6 alert categories while still achieving CPOE adoption of 75-78% during this period.

Physician adoption & governance strategies for a multi-facility EMR/CPOE implementation.

Significant challenges surround CPOE systems in community hospital. Our strategies focused on key physicians, representing a majority of inpatient activity, targeting them with specific support to maximize their readiness and understanding of the upcoming change environment. Key among these was assigning to meet all their educational, technical and support needs. A broad enterprise-wide physician steering group was involved with all physician design decisions and charged with aggressively communicating these decisions. We believe our success to date is directly attributable to the early and aggressive use of such engagement strategies.

Antibiotic prophylaxis in infants and young children with cystic fibrosis: a randomized controlled trial.

OBJECTIVES: To evaluate whether antistaphylococcal prophylaxis in infants and young children with cystic fibrosis (CF) would suppress the acquisition of Staphylococcus aureus and delay the onset of the manifestations of bronchopulmonary disease. STUDY DESIGN: A 7-year, multicenter, double-blind, placebo-controlled study of continuous antistaphylococcal therapy. Otherwise healthy children <2 years of age with CF were randomly assigned to be treated with daily cephalexin (80-100 mg/kg/day) or placebo. Clinical, microbiologic, laboratory, radiographic, and anthropometric outcomes were evaluated. RESULTS: Of 209 children enrolled, 119 completed a 5- to 7-year course of therapy. Mean age at enrollment was 15.6 and 14.1 months in the cephalexin and placebo groups, respectively. Respiratory cultures from children treated with cephalexin were significantly less likely to be positive for S aureus (6.0% vs 30.4%; P <.001). They were, however, much more likely to be positive for Pseudomonas aeruginosa (25.6% vs 13.5%; P <.009). These differences became apparent in the first year after enrollment and persisted over the duration of the study. In contrast to these microbiologic differences, there were no differences in clinical outcome measures, including radiographic (Brasfield score, 23.4 vs 23.2) or anthropometric scores or pulmonary function. CONCLUSIONS: Although long-term prophylaxis with cephalexin successfully delayed the acquisition of S aureus, it enhanced colonization with P aeruginosa and did not lead to clinically significant improvement in major health outcomes. These data do not support routine antistaphylococcal prophylaxisin otherwise healthy infants and young children with CF.